Get Single Case Agreement Template

Completing the Single Case Agreement Template can seem daunting, but with the right guidance, it can be a straightforward process. This comprehensive guide will walk you through each section of the template to ensure you provide all necessary information accurately.

Follow the steps to complete the Single Case Agreement Template effectively.

1. Press the ‘Get Form’ button to access the Single Case Agreement Template and open it in your preferred online editor.
2. Begin with the member information section. Enter the member's name, ID number, and date of birth in the designated fields.
3. Next, fill out the ordering provider information. This includes the provider's name, tax identification number or national provider identifier, address, and phone number. Make sure to identify who completed the request and include their fax number.
4. In the servicing provider/facility information section, provide the servicing provider's or facility's name, TIN/NPI, address, and phone number. Also, include the name of the administrative contact and their fax number. Ensure you have an active AHCCCS ID before submitting.
5. Select the type of request from the available options: either Single Case Agreement or Extend/Add Services for an Existing Single Case Agreement.
6. Describe the reason for the contract or the clinical rationale for needing to go outside the network in the provided space.
7. Specify the desired contract effective date by filling in the start and end dates.
8. Input the diagnosis code(s) and CPT code(s) relevant to the request.
9. Indicate the number of treatments or visits being requested.
10. Finally, be sure to attach any additional documentation specific to the request to prevent delays in processing. After completing the form, save your changes. You can also download, print, or share the filled form as needed.

Complete your documents online to ensure a smooth and efficient process.