Get 16361 2020-2024
Ns are required only if the patient s stay is over 48 hours for vaginal birth or 96 hours for a C-section, from the date of delivery. Fax this completed form to 800-843-1114. Complete all required* fields. *Member ID: *Patient name: Maternity only (ill newborn): Birth mother s name: *DOB: Baby gender: Facility Contact: Facility: *Contact name: *Facility name: *Phone: *Address: *Fax: *City/State/ZIP: Utilization Review Information: *TIN # (required): *Phone: *Type *Fax: Admis.
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