Azfmc

Please fill out the form below to submit your request for pre-certification.
Required fields are marked with an asterisk (*).

Your Info

— 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


Patient Info

— Select — Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming


Insured Info

Only enter the insured’s name if it is different than the patient name.


Service Info
Please enter the primary diagnosis description and/or code. You may also add up to 5 additional diagnoses if necessary.

Please enter the primary procedure description and/or code. You may also add up to 5 additional procedures if necessary.


Admit date, date of service, or EDC if OB notification

— Select — In Patient
Out Patient
Physician’s Office
Homecare
Durable Medical Equipment


Provider Info

— Select — Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming

This information is required on all Ancillary Claims.


Facility Info

Copy Provider Info to Facility

— Select — Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming


Clinical Info
Your pre-certification request must be submitted with appropriate clinical information in order to be processed. Please select an option below.


Additional Notes
Please enter any additional instructions, comments, or notes 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.