Get Cape Cod Healthcare Inc - Full Filing- Nonprofit Explorer

Completing the Cape Cod Healthcare Inc - Full Filing- Nonprofit Explorer is an important step in managing healthcare services effectively. This guide provides clear instructions to help you navigate through the form with ease.

Follow the steps to accurately fill out the form

1. Click ‘Get Form’ button to access the form and open it for completion.
2. Begin filling out the patient information section. Enter the patient's name, date of birth, address, city, state, ZIP code, phone number, Tufts member ID, and email address.
3. In the facility section, select the type of service required by checking either 'Lab Services' or 'Radiology/Imaging'. Fill in the facility name, hospital or surgery center, and dates of service requested. Also, provide the facility's National Provider Identifier (NPI) number, address, city, state, phone number, and ZIP code.
4. Address the question about prior treatment at the facility by circling 'Yes' or 'No'. If 'Yes', provide the date when the patient was last seen at the facility.
5. State the reason for the request by choosing the applicable option such as being seen by a DPO specialist or the service being unavailable in the CCHC DPO network. Add any additional description of the service requested.
6. Lastly, the requestor must sign and date the form authorizing the release of information to the provider as necessary for review.
7. Once all fields are completed, review the form for accuracy. You can then save your changes, download the form, print it, or share it as needed.

Complete your forms online for efficient healthcare management today.