Access Health Pre-Certification REQUEST

PRE-CERTIFICATION REQUEST

Please allow at least 10 business days for processing of Pre- certification requests.

Date of request:

Patient Name:

Employer Name:

Groups Number:

Member ID Number:

ICD-9 Code:

Diagnosis Description:

Additional Information (if Any):

Requesting Provider Name & Address:

Name:

Address:

Phone #:

Fax #:

Requested Provider Information:

Please choose one of the following Requested Providers:

Please add your providers Name, Address, City, State, Zip Code and Phone Number if not in the list above:

Name:

Address:

City:

State:

Zip Code:

Phone #:

Fax #:

Name of person completing the form.

Email of person completing this form:

Requested Service:(S)

Inpatient Outpatient Hospital Office/Clinic

(Please check all that apply)

DME > $500 & Rentals

Elective IP Admission

MRI/MRA/PET scan

PT (after 1st 20 visits)

Radiation Therapy

Speech/Occupational Therapy

Chemotherapy

OP Surgery

OP Diagnostic Testing

Other: Please Describe

Care or Service Requested #1:

Care or Service Requested #2:

Care or Service requested #3:

Additional Care or Service Information/Description:

Anticipated/Scheduled Date of Requested Procedures

Instructions: If clinical documentation is being sent in support of this specialty referral request,additional information can be sent electronically using the Browse button and select documents to be included in your submission of this form or send via confidential fax to 866-245-9376. Please make sure you hit the submit button to send your request.

Additional information upload

Administrative Use Only:

Field 1:

Field 2:

For questions regarding specialty care referrals or use of this form, Please contact us at 866-245-9374 from 08:30am-04:30pm Monday through Friday for assistance.