Get Unicare Form 10 2016-2025

This guide provides clear instructions on how to complete the Unicare Form 10 online efficiently. This form is essential for obtaining precertification for enteral therapy and includes several important fields that require accurate information.

Follow the steps to fill out the Unicare Form 10 online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred digital editor.
2. Begin by entering the patient’s name, date of birth (DOB), and member ID in the designated fields. Ensure that all names are spelled correctly and that the DOB is in the correct format.
3. Next, input the provider's information, including their name, phone number, and fax number. Additionally, fill in the provider's complete address.
4. Continue by providing the ordering physician's details, which should include their name, contact information, and full address.
5. Specify the source of referral by selecting from the available options (Hospital, SNF, Rehab, Other). If you select 'Other', please detail the source.
6. Enter the diagnosis along with the corresponding ICD-10 code in the appropriate fields.
7. Don't forget to note the notification number, as this will be crucial for follow-up communications.
8. Indicate the patient’s living situation by selecting the appropriate option (Own home, SNF, Other) and specify if 'Other' is selected.
9. Provide details about where the treatment will occur. Be specific to ensure clarity for healthcare providers.
10. If the patient has a primary caregiver, indicate 'Yes' or 'No' and provide their name if 'Yes' is selected.
11. In the social factors section, describe any relevant family or community services that may be applicable.
12. Outline the services requested by providing the formula/supply name, dosage, route, frequency, start date, and stop date, including B codes for medications.
13. Indicate if skilled nursing services are included, how many visits are required, and ensure all information is accurate.
14. Finally, sign and date the form. Print your name and provide your phone number for contact purposes.
15. After completing the form and ensuring all information is accurate, save your changes. You may then download, print, or share the completed form as necessary.

Encourage users to complete their forms online for a streamlined process.