Get Ct Husky Health Inpatient Surgery/procedure Request Form 2016-2025

Filling out the CT Husky Health Inpatient Surgery/Procedure Request Form online is a straightforward process that can help ensure timely medical procedures for eligible members. This guide provides clear and concise steps to successfully complete the form and submit it for review.

Follow the steps to fill out the CT Husky Health Inpatient Surgery/Procedure Request Form

1. Press the ‘Get Form’ button to access the form and launch it in your preferred online editor.
2. Begin by entering the member's date of birth in the specified field.
3. Next, fill in the member's full name accurately as it appears on their health documentation.
4. Provide the member's identification number, ensuring it is correct for proper processing.
5. Select the appropriate health plan from the dropdown; in this case, it is HUSKY A.
6. Input the expected date of admission for the inpatient surgery or procedure.
7. Indicate the anticipated number of days the patient will spend in the hospital.
8. Specify the name of the hospital where the procedure will take place.
9. Fill out the billing hospital's CMAP ID to link the billing appropriately.
10. List the name(s) of the surgery or procedure(s) being requested.
11. Enter the relevant procedure code(s) associated with the requested surgery or procedure.
12. Provide the diagnosis code(s) that justify the need for the procedure.
13. Indicate the name and contact details of the surgeon or admitting physician.
14. Include the National Provider Identifier (NPI) number for the surgeon or admitting physician.
15. Enter the name of the contact person responsible for following up on the request.
16. Fill in the contact person's phone number for any required clarifications.
17. If applicable, include the fax number for additional communication or information sharing.
18. Review all entries thoroughly to ensure that each field is completed accurately.
19. Save your changes and download or print the completed form. Ensure to fax the form along with the required clinical notes to the specified number, 203.265.3994.

Complete your CT Husky Health Inpatient Surgery/Procedure Request Form online today!