Get Assistance Request Form For Clinical Certification All - Sgmc

Completing the Assistance Request Form for Clinical Certification is a crucial step in ensuring that patients receive the necessary care without delays. This guide will provide you with clear, step-by-step instructions on how to accurately fill out the form online, ensuring all required information is provided.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in your editing tool.
2. Indicate whether this request is for STAT service by checking the appropriate box. Also, specify the location where the service will be performed among the listed SGMC campuses.
3. Provide the patient information, including the patient's name, social security number, date of birth, phone number, and full address.
4. Fill out the procedure information section by entering the date of the request, contact person's name, date and time of the appointment (if scheduled), CPT codes, and ICD-9 codes. Include specifics about the extremities and the patient's orientation as inpatient or outpatient, specifying the length of stay if necessary.
5. If applicable, complete the surgery scheduling section by providing the name of the surgeon and the name of the in-office scheduler. Indicate the patient's status based on relevant options.
6. In the referring physician information section, enter the name and specialty of the referring physician, along with their address, city, state, NPI number, tax ID number, fax number, and phone number.
7. Include the necessary signature, authorizing SGMC to obtain authorization, and fill in the date.
8. Once all fields are completed and verified for accuracy, you can save changes, download, print, or share the form as needed.

Complete your assistance request form online today to ensure timely clinical certification.