Get Service Request Enrollment Form

Filling out the Service Request Enrollment Form online can seem daunting, but with clear instructions, it can be a straightforward process. This guide will walk you through each section of the form, ensuring you understand the requirements and can complete it with confidence.

Follow the steps to complete the Service Request Enrollment Form online.

1. Click ‘Get Form’ button to access the Service Request Enrollment Form and open it for editing.
2. Begin by selecting the program services you are requesting. This includes options for benefit coverage verification, prior authorization assistance, claim denial inquiries, or low payment appeals. Ensure you understand each selection as it pertains to your needs.
3. Provide physician information. Fill out the physician's name, specialty, state license, and NPI (National Provider Identifier). This section ensures that the healthcare provider's credentials are documented.
4. Obtain and include patient consent. Both the physician and the patient must complete their signatures to authorize the release of protected health information necessary for processing the request.
5. Provide detailed patient information, including full name, diagnosis/ICD-9 code, anticipated treatment date, and date of birth. Make sure that all data is accurate to prevent delays in processing.
6. Complete the insurance information section. Including the insurance company name, policy number, and any additional insurance details will facilitate coverage checks.
7. Once all sections are filled out, review the document for accuracy. After confirming that all information is complete and correct, you will have options to save changes, download, print, or share the form as needed.

Start filling out your Service Request Enrollment Form online today to ensure timely processing of your requests.