Get Unite Here Health (formerly Local 54) Precertification Fax Form

Filling out the Unite Here Health precertification fax form is a straightforward process that ensures proper authorization for medical services. This guide will help you navigate each section of the form to ensure a complete and accurate submission.

Follow the steps to accurately complete the precertification form online.

1. Press the ‘Get Form’ button to access the precertification fax form and open it in your preferred editor.
2. Provide patient and subscriber information. Fill in the patient’s name, ID number, date of birth, and gender. Next, complete the subscriber's name and relationship to the patient, including their date of birth.
3. Indicate whether there is any other insurance coverage by selecting 'Yes' or 'No.' If applicable, include the name of the other insurance carrier.
4. Specify if the service is related to a motor vehicle or workers' compensation claim by marking 'Yes' or 'No.'
5. Complete the physician information section, including the ordering physician's name, their specialty designation (PCP or specialist), and their NPI or TIN number.
6. Fill in the contact person's name along with their phone number and fax number.
7. Select the service for which authorization is being requested by marking the appropriate checkbox next to the relevant service or procedure.
8. Enter the procedure name, CPT code, and ICD-10 code as required.
9. Indicate the anticipated date of service using the provided fields.
10. Complete the facility/location information, including the name, city, state, and ZIP code.
11. If applicable, note the authorization status, including whether it is approved, denied, or pended, and include the necessary details and comments.
12. After completing the form, you can save your changes, download, or print the document for submission.

Complete your precertification documents online today for a smoother healthcare experience.