Get Pre Cert Form 062612 - Riskmgt Alabama

Filing the Pre Cert Form 062612 is essential for securing pre-authorization for medical procedures in Alabama. This guide will walk you through each section of the form, providing clarity and support to help you complete it successfully.

Follow the steps to fill out the Pre Cert Form 062612 accurately online.

1. Press the ‘Get Form’ button to access the Pre Cert Form 062612 and open it in an online editor.
2. Begin by filling in the patient's information, including their name, social security number, address, city, state, and zip code. Make sure this information is accurate to avoid any delays.
3. Provide the date of injury and, if known, the claim number to help associate this form with the correct case.
4. Indicate the body part(s) injured or involved, followed by the patient's date of birth. Also, include the patient's phone number. Ensuring this information is correct is vital for proper processing.
5. Specify the name of the procedure along with CPT codes if applicable. Clearly indicate the frequency and duration of the procedure, such as physical therapy or epidural steroid injections.
6. Fill in the date the procedure is scheduled for and the facility's name and city where the procedure will take place. This information supports the request for authorization.
7. In the 'Why?' section, detail the symptoms, physical exam results, previous test results, current treatment plan, medications, and any pre-existing conditions that may impact the treatment. Fax the latest clinical information to support this request.
8. Provide the physician ordering the procedure's name, along with the facility or physician group name, the staff member making the request, and their telephone and fax numbers.
9. Select the preferred method of contact and provide the necessary email and fax details. Make sure to include the date this request is being faxed.
10. Finally, indicate the best date and time to contact the ordering physician for a peer-to-peer discussion with the physician advisor.
11. After completing the form, you can save changes, download the form for your records, print it, or share it as needed.

Complete your Pre Cert Form 062612 online today to streamline your medical authorization process.