Get Unitypoint Out Of Network Request Recommendation Form

Completing the UnityPoint Out Of Network Request Recommendation Form online can streamline the process for obtaining necessary authorizations. This guide will provide clear, step-by-step instructions to ensure that you accurately fill out the form and submit it efficiently.

Follow the steps to complete your Out Of Network Request Recommendation form

1. Click ‘Get Form’ button to access the UnityPoint Out Of Network Request Recommendation Form and open it for editing.
2. Begin filling out the patient information section. Provide the patient's name, date of birth, and member number. Ensure all information is accurate to prevent processing delays.
3. Complete the service information section, including the start date for services, type of visit (consult, surgery/procedure, ongoing care), expiration date for services, number of visits, place of service, diagnosis (ICD10 code), and rationale for the out-of-network request.
4. In the provider information section, enter details about the provider to whom the patient is being referred. Include the practitioner's name, NPI number, specialty, address, and phone number.
5. Fill out the referred facility details, including the facility name, tax ID, and address.
6. Complete the referred by section with the practitioner who is making the referral, including their NPI number, name, and the clinic or facility they represent.
7. Ensure the form is completed by a person who is clearly identified in the 'Form Completed By' section by providing their name, phone number, fax number, and date.
8. Review the completed form for accuracy. Once verified, save your changes. You may choose to download, print, or share the form as needed.

Start filling out your UnityPoint Out Of Network Request Recommendation Form online today for a smooth authorization process.