Get Obstetrical Ultrasound Certification Request Form

This guide provides step-by-step instructions for completing the obstetrical ultrasound certification request form online. By following these instructions, users can ensure that all necessary information is accurately submitted to facilitate quick processing.

Follow the steps to complete the certification request form.

1. Click ‘Get Form’ button to obtain the form and open it in the designated editor.
2. Enter the patient's name in the designated field. Ensure that the name matches the identification documents to avoid discrepancies.
3. Input the patient's date of birth (DOB) using the provided format. This information is essential for verifying the patient's identity.
4. Provide the details of the patient's insurance plan, including the member ID number. This is necessary for insurance verification and approval.
5. Specify the referring physician’s name and their specialty. This formalizes the request and links it to a responsible party.
6. Fill in the physician's address, including city, state, and zip code. Accurate contact information is crucial for follow-up.
7. Input the physician's National Provider Identifier (NPI) number, essential for insurance claims and provider identification.
8. Document the date of request. This helps in tracking the timeline of the certification process.
9. Indicate the contact person for any inquiries regarding the request, including their contact details.
10. Enter the imaging facility's name, site phone number, and address, ensuring that the location is ready for the procedure.
11. Provide the proposed date of service for the ultrasound. This helps the reviewing team in scheduling.
12. Fill in the patient’s age at delivery to gather supportive data on the pregnancy situation.
13. Specify the CPT code(s) related to the procedure. This ensures the correct services are authorized.
14. Document the gestational age and the number of gestations, as this is critical for medical assessment.
15. State the reason for risk for pre-term labor, as this helps inform the urgency and necessity of the request.
16. Include cervical length from the last ultrasound if available. This aids in evaluating the pregnancy.
17. List current symptoms the patient is experiencing that may impact the ultrasound requests.
18. Provide results and dates of prior laboratory tests relevant to the pregnancy.
19. Document any maternal medical problems and medications, which are crucial for risk assessment.
20. Include any history of previous pregnancy complications or congenital anomalies to inform the reviewers.
21. Estimate the gestational weight and current estimated gestational age of the fetus.
22. Enter any documented fetal anomalies present in this pregnancy to highlight potential concerns.
23. Provide results of prior ultrasound exams if applicable, as this may provide additional context.
24. Add any other pertinent information that could assist in the evaluation of the request.
25. Finally, the requesting physician must sign and date the form to validate it before submission.
26. After completing the form, users can save changes, download, print, or share the form as needed.

Complete your obstetrical ultrasound certification request form online efficiently today.