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Pre-Cert Request
Please fill out the form below to submit your request for pre-certification. Required fields are
underlined
and marked with an asterisk (*).
Your Info
First Name *
Last Name *
Your E-Mail *
Who is requesting? *
Please Select...
Admissions
Business Office
Claims Payor
Client
Employer
Requestor
Member
Other Source
Patient
Patient Representative
PCP
Predictive Modeling
Provider of Care
Reinsurance Carrier
Specialist
Transistioned From Other CM Vendor
Utilization Review
Telephone *
(
)
-
Patient Info
First Name *
Last Name *
Date of Birth
Address
City
,
State
,
Zip
,
Select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Telephone
(
)
-
Insured Info
Insured's ID# *
Insurance Company
Only enter the insured's name if it is different than the patient name.
Insured's First Name
Last Name
Employer Name
Service Info
Please enter the primary diagnosis description and/or code. You may also add additional diagnoses if necessary.
Primary Diagnosis *
Code
Other Diagnosis 1
Code
Other Diagnosis 2
Code
Other Diagnosis 3
Code
Other Diagnosis 4
Code
Other Diagnosis 5
Code
Add Another Diagnosis
Please enter the primary procedure description and/or code. You may also add additional procedures if necessary.
Primary Procedure *
Code
Other Procedure 1
Code
Other Procedure 2
Code
Other Procedure 3
Code
Other Procedure 4
Code
Other Procedure 5
Code
Add Another Procedure
Date of Service *
Admit date, date of service, or EDC if OB notification
Type of Service *
Please Select...
In Patient
Out Patient
Physician's Office
Homecare
Durable Medical Equipment
Provider Info
First Name *
Last Name *
Referring Physician Name *
Address
City
,
State
,
Zip
,
Select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Tax ID Number
Telephone
(
)
-
This information is required on all Ancillary Claims.
Facility Info
Copy Provider Info to Facility
Facility Name *
Address
City
,
State
,
Zip
,
Select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Tax ID Number
Telephone
(
)
-
Clinical Info
Your pre-certification request must be submitted with the appropriate clinical information in order to be processed. Please select an option below.
Select An Option
Upload documents here
Fax separately
You will be given a fax cover sheet to print at the end of this form.
Clinical Info File *
Info File 2
Info File 3
Info File 4
Info File 5
Add Another File
Additional Notes
Please enter any additional instructions, comments, or notes below.
I have read the disclaimer below. *
Disclaimer:
We are certifying for medical necessity. We advise you to call the claims payor regarding benefits, eligibility and how this claim will be paid.