Get Facey Service Rquest Form Pdf

Completing the Facey Service Request Form online can streamline the process of requesting services efficiently. This guide provides clear instructions for filling out each section of the form, ensuring that you gather the necessary information accurately.

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

1. Press the 'Get Form' button to access the Facey Service Request Form Pdf and open it in your selected PDF editor.
2. Begin at the top of the form. Select Routine 1 for appointments within 15 business days or Routine 2 for appointments within 7 to 10 business days. If the request is urgent, you must call the Urgent/Stat Line at 818-837-5548 or extension 4423. If services have already been rendered, check Retro. If the referral is at the patient's request, check PR. Note that certain requests require the inclusion of your DEA number.
3. In the Specialty Services section, check either consult or follow-up as applicable. Indicate the type of consult or referral being requested, or write it in the space provided as 'other' if it is not listed. If there is a specific provider preference, please specify the name. If the selected provider is on the Select Provider List, it will be auto-authorized; otherwise, it will be reviewed. If no preference is stated, a provider will be selected from the Select Provider List.
4. In the Other Services section, note which services are required, paying attention to those marked with an asterisk. If selected, you will need to provide your DEA number. Indicate the service requested or write it as 'other' if not available. When ordering imaging studies, be specific about the site that requires imaging.
5. Include any relevant clinical information to be sent to the specialist. This should be checked as needed and copies of pertinent records or labs must be attached. This section is completed by the physician.
6. Fill out the Clinical Indications section with concise and legible information, as this will be transcribed for the IDX generated authorization for the consultant.
7. Sign and date the form to authenticate your request.
8. If applicable, input your DEA number in the space provided for any selected items marked with an asterisk.
9. Complete the Level of Service and Place of Service fields if the services are related to hospitals or surgery centers.
10. If desired, provide the specialty provider’s name, or this will be entered by the Specialty Request Service.
11. In the Patient Demographic Label section, either place the label or at a minimum, print the required information in the bolded areas.
12. Once all sections are completed, save your changes, then download, print, or share the form as needed.

Complete the Facey Service Request Form online today to ensure a smooth service request process.