Get Preferred: Fax Form And Relevant Clinical Documentation To (651) 662-2810 Or Mail

Filling out the Preferred: Fax Form and relevant clinical documentation can be straightforward with the right guidance. This guide provides clear instructions to assist users in completing the form accurately and efficiently.

Follow the steps to correctly fill out the form and submit it online.

1. Press the ‘Get Form’ button to access the Preferred: Fax Form and open it in your preferred editing tool.
2. In the 'Member Information' section, provide the member ID, group number, member name, and date of birth. Ensure that all names are spelled correctly to avoid any processing issues.
3. Complete the 'Member Address' section with the complete address, city, state, and zip code. Remember to include a valid phone number for contact purposes.
4. Fill in the 'Ordering Provider Information' with the provider's name, ID or NPI number, address, and phone number. This information is essential for validation.
5. In the 'Servicing Provider Information' section, input the servicing provider’s name, ID or NPI number, address, and contact information, including fax number.
6. Specify if the request is for an 'Inpatient/Outpatient Facility' by filling in the name and facility ID.
7. Under 'HCPC/CPT Code(s)', list the relevant codes along with their descriptions, ensuring they are accurate for the request.
8. Provide the 'ICD-10 Diagnosis Code(s)' relating to the member's condition.
9. Indicate the start and end dates for the requested services in mm/dd/yy format.
10. If applicable, complete the 'DME Charge Information/MSRP' section with accurate information.
11. Include any additional information or descriptions that may support your request on the form.
12. Before submitting, confirm that the total number of pages being faxed is filled in correctly. Finally, save changes, download, print, or share the form as needed.

Start filling out the Preferred: Fax Form and relevant clinical documentation online today!