Get Outpatient Request Form

Outpatient Request Form Fax to 1-888-299-4181 Request Priority Care must be rendered Service Type Requesting Provider Telephone Number Physical or Occupational Therapy Physician State License DME/Radiology Speech Therapy Billing Tax ID Outpatient Surgery Adjunctive Dental Is this a continuation/extension of services Date of Service mm/dd/yyyy Inpatient Behavioral Health IBH US Mail No Essential Service Information Inpatient Physical Health Yes Is the requesting provider performing the service Hospice/Respite Care IP Fax I Correspondence Preference IV Therapy/Home Health Q3 - Contact Name OP Behavioral Health OP Medical Care/Procedure Q2 outside 72 hours Specialty Referral/ Global Maternity Q1 within 72 hours Is this behavioral health PHP Is this an Initial 8 I Has this service been provided No I Is this a BH extension Patient Information Please complete all fields. Sponsor SSN / DOD Benefits Number Patient Name Last First MI / Patient Date of Birth Patient Address ZIP Code Street Patient Home Phone City State Other Health Insurance Servicing Provider Information Complete all applicable fields. Specialty Phone Address Facility Name If Applicable Requested Service Information Complete as many sections as required* Diagnosis Description Code Service 1 CPT/HCPC/NDC Code Number of Visits If DME Purchase IF DME Frequency If global maternity due date Duration Rental Attach clinical history/previous treatment/plan of treatment supporting lab/X-ray reports etc* if necessary. Confidentiality Note This facsimile and documents accompanying this facsimile transmission may contain confidential information* The information is intended only for the use of the individual or entity name above. If you are not the intended recipient or the person responsible for delivering it to the intended recipient you are hereby notified that any disclosure copying distribution or use of the information contained in this transmission is strictly PROHIBITED. If you have received this transmission in error please notify the sender immediately by telephone or by return FAX and destroy this transmission along with any attachments. Thank you. TRICARE is a registered trademark of the Department of Defense Defense Health Agency. All rights reserved* 01/29/2014 HF1213x041 10/14. Sponsor SSN / DOD Benefits Number Patient Name Last First MI / Patient Date of Birth Patient Address ZIP Code Street Patient Home Phone City State Other Health Insurance Servicing Provider Information Complete all applicable fields. Specialty Phone Address Facility Name If Applicable Requested Service Information Complete as many sections as required* Diagnosis Description Code Service 1 CPT/HCPC/NDC Code Number of Visits If DME Purchase IF DME Frequency If global maternity due date Duration Rental Attach clinical history/previous treatment/plan of treatment supporting lab/X-ray reports etc* if necessary. Specialty Phone Address Facility Name If Applicable Requested Service Information Complete as many sections as required* Diagnosis Description Code Service 1 CPT/HCPC/NDC Code Number of Visits If DME Purchase IF DME Frequency If global maternity due date Duration Rental Attach clinical history/previous treatment/plan of treatment supporting lab/X-ray reports etc* if necessary. Confidentiality Note This facsimile and documents accompanying this facsimile transmission may contain confidential information* The information is intended only for the use of the individual or entity name above. .