Get Pre-certification Request Form - Freedom Health

This guide will provide you with clear and step-by-step instructions on how to accurately complete the Pre-Certification Request Form for Freedom Health online. By following these directions, you will ensure that your pre-certification requests are processed efficiently and accurately.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by filling out the date of the request.
3. Next, provide the member information including their name, plan ID number, and date of birth in the designated fields.
4. In the requesting office section, enter the name of the office, tax identification number (TIN), phone number, and fax number.
5. For the facility requested, fill in the contact person's name and extension, along with the provider's name and TIN.
6. Check the box for Non-Participating Provider if applicable.
7. In the comments section, provide a brief clinical statement supporting the medical necessity for the requested procedure or service.
8. List the diagnosis related to the request in the designated areas.
9. Select the appropriate service(s) requested by checking the corresponding box(es) available.
10. Indicate the date of service.
11. Fill in the CPT or HCPC code(s) and ICD-9 code(s) where required.
12. Once all necessary information is completed, save your changes, and you may choose to download, print, or share the form as needed.

Take the first step and complete your Pre-Certification Request Form online today.