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Get 16361 2019

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: 888-742-1487. This number is also for faxing medical records. * Complete all required fields. *Member ID: *Patient name: Maternity only (ill newborn): Birth mother s name: *Date of birth: Baby gender: Facility Contact: Facility: *Contact name: *Facility name: *Phone: *Address: *Fax: *City/State/ZIP: Utilization review i.

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