Pre-Determination of Benefits Form. For Commercial Members Only. Fax completed form to: 866-756-9733. Note: To avoid delay in processing your request,...
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Pre-Determination of Benefits Form For Commercial Members Only Fax completed form to: 866-756-9733 Note: To avoid delay in processing your request, please fill out this form completely.
PHYSICIAN OR OTHER HEALTH CARE PROVIDER Physician or Provider Name
___________________________________
Physician or Provider Tax ID Address
__________________________________
______________________________________________
Name of Facility
_________________________________________
Facility Address
_________________________________________
Anticipated Date of Service
___ / ___ / ______ □
Inpatient
□
Outpatient
PATIENT INFORMATION Subscriber Name
________________________________________
Subscriber Number Patient Name
_______________________________________
__________________________________________
Patient Date of Birth
___ / ___ / ______
Group/Policy Number
______________________________________ SERVICE DESCRIPTION
Diagnosis Codes 1. 2. 3. 4.
1. 2. 3. 4.
CPT/HCPCS 5. 6 7. 8.
Comments/Notes Describing the Service:
___________________________________________________ ___________________________________________________ ___________________________________________________ ADDITIONAL INFORMATION Note: Please fax any documentation that will clarify your request with this form. Examples include:
• • • •
Test Results (lab, visual fields, radiology, sleep study, etc.) Patient’s Current Condition (height, weight, etc.) Pertinent History/Evaluation Progress Notes
