Get Emergency Room Notification Form - Magellan Of Iowa

Filling out the Emergency Room Notification Form is an essential process for ensuring timely authorization for care received at an emergency room. This guide will provide you with clear, step-by-step instructions to help you complete the form effectively.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Input the client’s name in the designated field. This section requires the full name of the individual receiving care.
3. Enter the name of the parent or guardian if applicable. This information is crucial if the client is a minor.
4. Fill in the Medicaid I.D. number. If applying for Medicaid, also include the social security number and date of birth in the specified fields.
5. Provide the client’s complete address, including city and zip code, to help identify the individual's residence.
6. Record the client’s phone number. This makes it easier for the authorization team to reach out if any issues arise.
7. Indicate the date of the emergency room visit by selecting the appropriate date from the date picker or typing it in.
8. Specify the hospital where authorization is being requested. This should be the facility where the emergency service was provided.
9. List the contact person and their phone number at the hospital. This person may need to be reached for additional information.
10. Indicate whether an ambulance authorization is needed by selecting 'Yes' or 'No'.
11. Provide the primary diagnosis treated in the emergency room. Include the necessary DSM-5 or ICD-9 numeric code for authorization.
12. Finally, enter the follow-up outpatient provider's information, if applicable.
13. Ensure the form is fully completed as it must be faxed to Magellan within 10 calendar days of the ER visit for payment consideration.
14. Once all information is filled out, save changes, download, print, or share the form as needed.

Complete the Emergency Room Notification Form online today to ensure timely processing.