Exceeding Your Expectations

Information About Services Requested

ePrecert

Dates of Service, Diagnosis, and Procedure Codes

(Enter all that apply - enter "None" in first line if none apply for that category):

Patient Information

This block contains code to alter the form appearance This block will not be visible on the live site.

DO NOT DELETE

Insured Information

Providing Facility/Doctor/Vendor Information

PROVIDERS/VENDORS: PLEASE FAX A COPY OF THE INSURANCE ID CARD AND CLINICAL INFORMATION FOR THIS CASE TO 765.447.8335 FAILURE TO FAX OVER INFORMATION REQUIRED WILL RESULT IN DELAY OR POTENTIAL CLOSURE OF REVIEW PROCESS.