Pre-Cert Request

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

Your Info

First Name *

Last Name *

Your E-mail *

Who is requesting? *

Telephone *

Extension

Patient Info

First Name *

Last Name *

Date of Birth

Address

City

State

Zip

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 up to 5 additional diagnoses if necessary.

Primary Diagnosis *

Primary Diagnosis Code

Other Diagnosis 1

Other Dx Code1

Other Diagnosis 2

Other Dx Code2

Other Diagnosis 3

Other Dx Code3

Other Diagnosis 4

Other Dx Code4

Other Diagnosis 5

Other Dx Code5

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

Primary Procedure *

Code

Other Procedure 1

Other Procedure Code 1

Other Procedure 2

Other Procedure Code 2

Other Procedure 3

Other Procedure Code 3

Other Procedure 4

Other Procedure Code 4

Other Procedure 5

Other Procedure Code 5

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

Facility Name *

Address

City

State

Zip

Tax ID Number

Telephone

Clinical Info

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

Upload documents here (5 MB limit) *

Fax separately (when faxing, do not upload documents here) *

Clinical Info File

Info File 2

Info File 3

Info File 4

Info File 5

Additional Notes

Please enter any additional instructions, comments, or notes below.

Notes

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.

Pre-Cert Request

Review Pre-Cert Request