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Get Single Case Agreement Template
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How to fill out the Single Case Agreement Template online
Filling out the Single Case Agreement Template is essential for individuals seeking to utilize out-of-network professionals with Cenpatico. This guide will walk you through each section, ensuring you complete the form accurately and efficiently.
Follow the steps to fill out the Single Case Agreement Template correctly.
- Press the ‘Get Form’ button to access the Single Case Agreement Template and open it in your preferred online editor.
- Complete the member information section by providing the individual's name, date of birth, member ID number, and indicate whether the member is a Medicare user.
- In the provider information section, enter the provider's name, licensure, date of birth, social security number, group name (if applicable), tax ID, rendering provider NPI, and Medicaid number.
- Fill in the phone number, Medicare number (if applicable), fax number, point of contact name, email address, and mailing address, including city, state, and zip code.
- Specify the dates of service and list the procedure codes requested along with the respective diagnosis code.
- In the Single Case Agreement rationale, select the reasons applicable to the request, such as provider specialization or lack of in-network providers in the area.
- Ensure all fields are completed, as submission requires every section to be filled out. Additionally, prepare to attach a W9 form, proof of insurance, and a copy of the provider's license.
- Once the form is complete, save your changes, then proceed to fax the completed document to Cenpatico Single Case Agreements at 866.374.1576.
Complete your Single Case Agreement Template online today to access the services you need.
Making a simple agreement letter involves clearly stating the intention of the agreement, along with the involved parties' names and contact details. You should also define the terms and conditions in straightforward language. Using a Single Case Agreement Template can help you draft a comprehensive agreement letter, minimizing the risk of misunderstandings.
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