Get Fax Cover Sheet - Inmatedocx - Accg

Filling out the FAX Cover Sheet - Inmatedocx - Accg is a straightforward process that enables users to submit a repricing request for inmate medical care. This guide will provide clear and detailed instructions on completing the form accurately and efficiently.

Follow the steps to complete your FAX Cover Sheet online.

1. Click ‘Get Form’ button to obtain the form and open it in the editing platform.
2. Enter the date in the designated field at the top of the form. This date should correspond to when you are completing the submission.
3. Fill in the number of pages you are submitting in the appropriate box to ensure the recipient is aware of the total documentation.
4. Indicate if the submission is an emergency by marking the 'Emergency' checkbox. This will alert the claims administration services to prioritize your request.
5. Identify the recipient by entering the full name 'Claims Administration Services' in the ‘TO’ field.
6. Complete the ‘Inmate’ and ‘Inmate Medical Care’ sections with the relevant details pertaining to the inmate requiring medical care.
7. Provide the email address in the ‘Email’ field, ensuring it's accurate for communication purposes. Use ACCGInmateCare@accg.org as directed.
8. Enter the fax number where documents will be sent, which is 678-225-4240, as specified in the instructions.
9. Attach the relevant medical bill for emergency health care to the form. Ensure you have a clear understanding that you will be billed based on Georgia Medicaid rates.
10. Sign and print your name in the indicated fields to authenticate the document. Also, include the county's name where required.
11. Fill in the telephone number associated with the county office to facilitate further communication if necessary.
12. Once all fields are completed, review your form for accuracy. Save the changes, and then you may download, print, or share the final document as needed.

Complete your FAX Cover Sheet online with confidence by following these steps.