Get For Repeat Endoscopy - Upmc Health Plan

Filling out the For Repeat Endoscopy form from UPMC Health Plan is an essential step for ensuring proper medical treatment. This guide will provide you with clear instructions on how to complete each part of the form efficiently.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to access the form and open it in your preferred form editor.
2. Begin by entering the patient name in the designated field. Ensure that you spell the name correctly.
3. Next, provide the patient's insurance ID. This is typically found on their insurance card.
4. Fill in the date of birth for the patient. Use the format MM/DD/YYYY to maintain consistency.
5. Enter the home address of the patient, including street, city, state, and zip code.
6. Input the patient’s phone number for any follow-up communication.
7. Enter the requesting provider's details, including name, phone number, address, and fax.
8. Provide the ICD-9 diagnosis codes relevant to the patient's condition.
9. List the CPT service or procedure codes that are applicable for the requested endoscopy.
10. Indicate the reason for the repeat endoscopy by selecting from the provided list, ensuring to specify any relevant alarm symptoms.
11. Attach the required documentation to support the medical necessity, including chart notes or physician attestations along with specific endoscopy reports.
12. Review all the information entered to ensure accuracy and completeness.
13. Once all fields are filled correctly, save changes. You may choose to download, print, or share the completed form as needed.

Complete the For Repeat Endoscopy form online today to ensure timely medical care.