Loading
Form preview picture

Get Rosomoy Gupta Pdf

If you are not the intended recipient please return the original message and notify Mercy Care Plan immediately. Fax 602 798-2576 or 602 431-7555 or Toll Free 800 217-9345 Mailing Address 4350 E* Cotton Center Blvd Building D Phoenix AZ 85040 DENTAL PRIOR AUTHORIZATION REQUEST FORM COMPLETE ALL MEMBER DATA BELOW Member Name Member ID Number Member Address Member Date of Birth Member Phone Number MCP/AHCCCS Member MCP DDD/ALTCS Member COMPLETE ALL DENTAL PROVIDER DATA BELOW Requesting Dentist Name Provider ID Number Office Address Office Phone Office Fax Office Contact CHECK THE APPROPRIATE REQUEST Please write clearly TREATMENT PLAN The entire proposed treatment plan exceeds 1 000 and/or requires prior authorization* Attach the proposed treatment plan with cost estimates. Include additional documentation as required per the Dental Provider Manual and/or Dental Matrix. Emergency services that do not receive a prior authorization will be retro-reviewed for appropriateness. The prior authorization number must be written on the dental claim for processing* SPECIALTY REFERRAL Pedodontist Oral Surgeon Endodontist Other MCP Dental Specialist Name Reason for Referral Diagnosis and Tooth Number if applicable Medical Alert/Special Needs X-rays Enclosed X-rays to be returned to provider MCP USE ONLY Prior Authorization Number Auth Expiration Date Comments Approval Signature Date Signed VERIFY MEMBER ELIGIBILITY ON EACH DATE OF SERVICE CONFIDENTIALY NOTICE The information contained in this transmission is private. It may also be legally privileged and/or confidential information of Schaller Anderson or a third party authorized only for the use of the intended recipient. Fax 602 798-2576 or 602 431-7555 or Toll Free 800 217-9345 Mailing Address 4350 E* Cotton Center Blvd Building D Phoenix AZ 85040 DENTAL PRIOR AUTHORIZATION REQUEST FORM COMPLETE ALL MEMBER DATA BELOW Member Name Member ID Number Member Address Member Date of Birth Member Phone Number MCP/AHCCCS Member MCP DDD/ALTCS Member COMPLETE ALL DENTAL PROVIDER DATA BELOW Requesting Dentist Name Provider ID Number Office Address Office Phone Office Fax Office Contact CHECK THE APPROPRIATE REQUEST Please write clearly TREATMENT PLAN The entire proposed treatment plan exceeds 1 000 and/or requires prior authorization* Attach the proposed treatment plan with cost estimates. Include additional documentation as required per the Dental Provider Manual and/or Dental Matrix. Emergency services that do not receive a prior authorization will be retro-reviewed for appropriateness. Include additional documentation as required per the Dental Provider Manual and/or Dental Matrix. Emergency services that do not receive a prior authorization will be retro-reviewed for appropriateness. The prior authorization number must be written on the dental claim for processing* SPECIALTY REFERRAL Pedodontist Oral Surgeon Endodontist Other MCP Dental Specialist Name Reason for Referral Diagnosis and Tooth Number if applicable Medical Alert/Special Needs X-rays Enclosed X-rays to be returned to provider MCP USE ONLY Prior Authorization Number Auth Expiration Date Comments Approval Signature Date Signed VERIFY MEMBER ELIGIBILITY ON EACH DATE OF SERVICE CONFIDENTIALY NOTICE The information contained in this transmission is private.

How It Works

AUTH rating
4.8Satisfied
45 votes

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

How to fill out and sign Expiration online?

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

Feel all the benefits of submitting and completing forms on the internet. Using our service submitting Mercy Care usually takes a couple of minutes. We make that possible through giving you access to our feature-rich editor capable of changing/correcting a document?s initial textual content, adding unique fields, and e-signing.

Complete Mercy Care in several clicks by simply following the instructions below:

  1. Select the template you will need from our collection of legal form samples.
  2. Select the Get form button to open it and start editing.
  3. Fill in all the necessary fields (they are yellowish).
  4. The Signature Wizard will help you add your e-signature after you have finished imputing information.
  5. Add the relevant date.
  6. Look through the whole template to make sure you?ve filled in all the information and no changes are required.
  7. Hit Done and save the ecompleted form to your gadget.

Send your new Mercy Care in a digital form when you are done with filling it out. Your information is securely protected, as we adhere to the latest security criteria. Become one of millions of satisfied clients that are already submitting legal templates straight from their houses.

Get form

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

ELIGIBILITY 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 Mercy Care

  • ALTCS
  • CONFIDENTIALY
  • AUTH
  • Endodontist
  • appropriateness
  • az
  • ELIGIBILITY
  • applicable
  • referral
  • blvd
  • exceeds
  • Expiration
  • recipient
  • Revised
  • Mailing
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.