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

Patient Info

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 *

Provider Info

First Name *		Last Name *
Referring Physician Name *
Address
City, State, Zip	,
Tax ID Number
Telephone	( ) -
	This information is required on all Ancillary Claims.

Facility Info Copy Provider Info to Facility

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.

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