Get Single Case Agreement Form

Filling out the Single Case Agreement Form online can seem daunting, but with the right guidance, it becomes a straightforward process. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member information. Fill out the fields for the member's name, date of birth, and member ID. Indicate whether the member is a Medicare recipient by selecting 'Yes' or 'No'.
3. Next, provide the provider information. Input the provider's name, licensure type, date of birth, social security number, group name (if applicable), tax ID, rendering provider NPI, Medicaid number, Medicare number (if applicable), phone number, fax number, point of contact name, email address, and mailing address.
4. Fill in the dates of service, requested procedure code(s), and diagnosis code. Ensure this information is accurate as it pertains to the services requested.
5. In the Single Case Agreement rationale section, select the appropriate reasons that justify the request, such as continuity of care or lack of in-network providers in the area.
6. Review the completed form to ensure all fields have been filled accurately. Confirm that you have attached any additional required documents, including the W-9, proof of insurance, and a copy of your license.
7. When you are satisfied with the form and your attachments, save your changes, download the form for your records, and fax it to Cenpatico Single Case Agreements at 866.374.1576.

Complete your Single Case Agreement Form online today and ensure all required information is accurately submitted.