Date:
Billing Provider:
Billing Address:
TIN:
Contact Person:
Phone:
Fax:
Patient:
DOB:
Member:
Member Id:
HCPCS and/or CPT Code(s):
Diagnosis Code:
Physician’s Name:
485 provided	Yes            No

# 1 most recent clinical note must accompany request:

PLEASE LIST TOTAL # OF SERVICES AND FREQUENCY REQUESTED FOR EACH SPECIALTY (EX: 1 W 1, 2 W 2)

SNV		Frequency:		W	,		W
PT		Frequency:		W	,		W
OT		Frequency:		W	,		W
ST		Frequency:		W	,		W

START DATE:
ENDING DATE:

# 2 most recent clinical note must accompany request:

PLEASE LIST TOTAL # OF SERVICES AND FREQUENCY REQUESTED FOR EACH SPECIALTY (EX: 1 W 1, 2 W 2)

SNV		Frequency:		W	,		W
PT		Frequency:		W	,		W
OT		Frequency:		W	,		W
ST		Frequency:		W	,		W

START DATE:
ENDING DATE:

# 3 most recent clinical note must accompany request:

PLEASE LIST TOTAL # OF SERVICES AND FREQUENCY REQUESTED FOR EACH SPECIALTY (EX: 1 W 1, 2 W 2)

SNV		Frequency:		W	,		W
PT		Frequency:		W	,		W
OT		Frequency:		W	,		W
ST		Frequency:		W	,		W

START DATE:
ENDING DATE:
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** All information is required for review. Information provided is private and confidential. **

NOTE: These benefits are applicable only if the patient is an eligible enrolled member of a HealthChoice plan. All benefits are subject to the deductible, coinsurance and policy provisions. Please verify benefits and eligibility by calling the medical claims administrator toll-free at 800-323-4314.

MEDICARE PATIENTS: If HealthChoice provides coverage that is supplemental to Medicare, all requested services must be approved by Medicare. The Medicare EOB should be filed for claims processing.