Get Anthem Request Form 2018 (61078 - Activated, Traditional)

The ANTHEM Request Form 2018 is essential for submitting therapy requests for members in New Hampshire and Connecticut. This guide will assist you in navigating each section of the form online to ensure a thorough and correct submission.

Follow the steps to effectively complete the form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. Begin by filling in the patient information section. Input the ANTHEM Member ID Number, first name, last name, and date of birth. Ensure accuracy, as this data is vital for identification.
3. Complete the therapy provider information section. Enter the facility or provider name, street address, city, state, telephone number, ZIP code, and fax number for responses. This information will facilitate communication regarding the request.
4. In the request information section, input the effective date for the request. Specify whether this is for the onset of therapy services, an extension, or a recurrence. Fill in the number of therapy visits to date, selecting the correct month and year.
5. Indicate the setting of the requested therapy services, which may include options like physical therapy or occupational therapy. Include details about the date of the last therapy visit and any additional management service needed.
6. If applicable, fill in details regarding the condition type, including the primary diagnosis code and affected region. Specify if the condition is acute, sub-acute, or chronic.
7. For post-operative cases, provide the type of surgery and the date of the surgery. Include chief complaints and frequency of symptoms to give a clear picture of the patient's current status.
8. Lastly, review all sections of the form for accuracy. Save your changes, download, print, or share the completed form as appropriate.

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