Loading
Form preview picture

Get PacifiCare SecureHorizons Treatment Authorization Form 2000-2024

ROUTINE TREATMENT AUTHORIZATION FORM Prior Auth. Fax 800 457-3828 Home Health Auth. Fax 800 207-1833 DME Auth. Fax 800 710-8812 PLAN TYPE Commercial Secure Horizons URGENT STAT From Name Address City State Zip Phone Fax Back No. THIS PORTION TO BE COMPLETED BY PHYSICIAN Patient Name Primary Care MD Refer To City State Zip Specialty Home Sex DOB Age Member ID Office Type of Service Inpatient Outpatient Home Health DME Office Fax Initial Visit Return Visit Other CLINICAL HISTORY PHYSICAL FINDINGS REASON FOR REFERRAL Consultation Testing Follow-up Procedure No. of Visits Requested DIAGNOSIS ICD-9 CM CODE EVALUATION TREATMENT PLAN RVS/CPT 4 CODE REQUESTED FACILITY Accident Yes No Occurrence Work Auto Other Insurance MD Signature Date NOTE The member has the right to appeal denial of services through PacifiCare/Secure Horizons PLEASE CHECK ELIGIBILITY PRIOR TO PROVIDING SERVICE. Authorization Provider Contracted Yes Facility Contracted Assigned Length of Stay Authorized Initials Pended Modified CPT Codes Authorized/No. of Visits Reason SE 7-26-00. ROUTINE TREATMENT AUTHORIZATION FORM Prior Auth. Fax 800 457-3828 Home Health Auth. Fax 800 207-1833 DME Auth. Fax 800 710-8812 PLAN TYPE Commercial Secure Horizons URGENT STAT From Name Address City State Zip Phone Fax Back No* THIS PORTION TO BE COMPLETED BY PHYSICIAN Patient Name Primary Care MD Refer To City State Zip Specialty Home Sex DOB Age Member ID Office Type of Service Inpatient Outpatient Home Health DME Office Fax Initial Visit Return Visit Other CLINICAL HISTORY PHYSICAL FINDINGS REASON FOR REFERRAL Consultation Testing Follow-up Procedure No* of Visits Requested DIAGNOSIS ICD-9 CM CODE EVALUATION TREATMENT PLAN RVS/CPT 4 CODE REQUESTED FACILITY Accident Yes No Occurrence Work Auto Other Insurance MD Signature Date NOTE The member has the right to appeal denial of services through PacifiCare/Secure Horizons PLEASE CHECK ELIGIBILITY PRIOR TO PROVIDING SERVICE* Authorization Provider Contracted Yes Facility Contracted Assigned Length of Stay Authorized Initials Pended Modified CPT Codes Authorized/No* of Visits Reason SE 7-26-00. .

How It Works

dob rating
4.8Satisfied
100 votes

Tips on how to fill out, edit and sign MD online

How to fill out and sign Consultation online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Are you seeking a fast and efficient tool to fill out PacifiCare SecureHorizons Treatment Authorization Form at a reasonable cost? Our platform gives you an extensive library of templates available for filling in on the internet. It only takes a couple of minutes.

Stick to these simple steps to get PacifiCare SecureHorizons Treatment Authorization Form completely ready for sending:

  1. Find the form you want in our collection of legal templates.
  2. Open the document in the online editing tool.
  3. Look through the instructions to learn which data you need to give.
  4. Select the fillable fields and include the requested info.
  5. Add the relevant date and place your electronic autograph as soon as you fill out all of the fields.
  6. Examine the form for misprints along with other mistakes. In case you need to correct something, the online editor and its wide variety of instruments are available for you.
  7. Save the filled out document to your gadget by hitting Done.
  8. Send the electronic form to the parties involved.

Filling out PacifiCare SecureHorizons Treatment Authorization Form doesn?t really have to be confusing anymore. From now on comfortably cope with it from your home or at your place of work right from your smartphone or desktop computer.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing cm

Experience the quickest and most accurate method to complete your Form. Watch the video guide and follow our guidance on how to complete the form on the web and without errors.

OUTPATIENT FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Keywords relevant to PacifiCare SecureHorizons Treatment Authorization Form

  • cpt
  • inpatient
  • dob
  • ELIGIBILITY
  • cm
  • referral
  • OUTPATIENT
  • ur
  • MD
  • Horizons
  • occurrence
  • consultation
  • provider
  • contracted
If you believe that this page should be taken down, please follow our DMCA take down processhere.
Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • 
                            VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • 
                            TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.