Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the type of service by checking all applicable options: INPT--OP or ROLLOVER.
3. Fill in the inquirer’s name, phone number, and return fax number in the designated fields.
4. Enter the department name where the inquiry is being made.
5. Complete the patient information section: input the patient's name, date of birth, and address.
6. Add the patient's ID number and indicate if it is a maternity admission by checking the appropriate boxes (VAG or C SECTION).
7. Describe the diagnosis, preferably using a code if available, in the designated field.
8. Circle the place of service from the options provided: ACUTE HOSP, I/P REHAB, ER, or SNF.
9. Circle the type of service rendered: MED, SURG, HOSPICE, or REHAB.
10. Indicate if a facility INN applies by checking the corresponding box.
11. Input the facility name, phone number, and full address in the appropriate sections.
12. Provide the facility Tax ID.
13. Indicate if the provider INN applies by selecting the appropriate option.
14. Fill in the attending physician's name, phone number, and full address.
15. Provide the physician's Tax ID.
16. If applicable, add procedure codes in the designated area. Note that this is not required for ER admits.
17. Enter the admit date and time, plus the medical record number.
18. Review all the entered information for accuracy.
19. Save your changes, download, print, or share the completed form as needed.

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