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Get Facey Service Rquest Form Pdf

Facey Medical Group Service Request Form Orientation Checklist for Required Fields Form is to be used for all HMO service requests both internal and external Form is to be completed by the physician only. Note that anything in a box is absolutely required information* The referral WILL NOT be processed without these areas being completed* Top of Form Required a* Check Routine 1 for appt w/in 15 business days or Routine 2 for appt w/in 7 to 10 business days. Urgent and Stat requests must be called in to Urgent/Stat Line 818-837-5548 or extension 4423. Check Retro if service/s have been rendered already. Check PR if referral is per patient request. b. Note the asterisk noting that certain requests require the DEA number Specialty Services or Other Services Required a* Check consult vs. follow-up b. Check the type of consult or referral being requested or if not found write it in the space provided as other c* If you or the patient has a specific provider preference please specify the name. i. If the name is on the Select Provider List it will auto-auth ii. If not it will go to UM for review d. If there is no preference for the specialist one will be selected from the Select Provider List favoring Facey physicians. The Select Provider List is stratified by geography. Other Services or Specialty Service Required number in the space provided* b. Check the service requested or if not found write it in the space provided as other c* When ordering imaging studies BE SPECIFIC specify the site brain LS-spine Knee etc* requiring the imaging. Clinical info to be sent to specialist check as needed* Attach copies of records labs. by MD and ICD-9 by MA Required Clinical Indications Required a* This information will be transcribed from this form to the IDX generated authorization* It will therefore be available for the consultant on the auth. b. Please put concise but PERTINENT AND LEGIBLE information in this area* Sign and date the form Required Place your DEA number in the provided space if you checked an item with an asterisk Level of Service and Place of Service needs completion for services in hospitals or surgery centers Specialty Provider s Name if desired or will be entered by the SRS Patient Demographic Label Required a* Place Label or at a minimum print information in the bolded areas. Note that anything in a box is absolutely required information* The referral WILL NOT be processed without these areas being completed* Top of Form Required a* Check Routine 1 for appt w/in 15 business days or Routine 2 for appt w/in 7 to 10 business days. Urgent and Stat requests must be called in to Urgent/Stat Line 818-837-5548 or extension 4423. Check Retro if service/s have been rendered already. Urgent and Stat requests must be called in to Urgent/Stat Line 818-837-5548 or extension 4423. Check Retro if service/s have been rendered already. Check PR if referral is per patient request. b. Note the asterisk noting that certain requests require the DEA number Specialty Services or Other Services Required a* Check consult vs.

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