ON-ISLAND PRE-CERTIFICATION FORM
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REGULAR
URGENT
RETRO
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Commercial/PPO
Commercial- Advantage HMO/POS
United Airlines
United Plan:
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Patient Name
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DOB
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-
Month
-
Day
Year
Date
Member ID
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Insured Name
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Home Number
Cell Phone Number
Requesting Provider Name
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TIN #
Contact Person
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Office Phone #
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Fax #
Alternate Phone #
Clinic Name
TIN #
Contact Person
Office Phone #
Fax #
Alt. Phone #
ICD9 Code(s)
Procedure/CPT Code (s)
Date of Service
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-
Month
-
Day
Year
Date
Out-Patient Setting
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Surgi-Center
Clinic
In-Patient
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YES
NO
Admit Date
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-
Month
-
Day
Year
Date
Requested # of Visits
Requested Facility/Provider for the Procedure
Comments:
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SIGNATURE OF REQUESTING PHYSICIAN
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