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Fax: 509-328-9777

Request for Medical Case Management

Requester Information
Requested By First & Last Name
Employer Group
Insured Group Number
E-mail Address
Phone Number ### ###-####
Fax Number ### ###-####
Check Case Type

Please choose a Case Type

Outreach Team Referral

MSW Only Referral

COPE Referrals
Patient Information
Patient's Name First & Last Name
Patient's Date of Birth MM / DD / YYYY
Patient's Address
Street Address

City

State / Province / Region

Postal / Zip Code
Member/Patient ID
Patient's Home Phone ### ###-####
Patient's Cell Phone (### ###-####
Patient's Work Phone ### ###-####
Insured Relationship
Provider Information
Date(s) of Service

Format: MM/DD/YYYY Separate Multiple Dates with a Comma (,)
Attending Physician #1 Title, First & Last Name
Physician #1's Phone Number ### ###-####
Physician #1's Fax Number ### ###-####
Physician #1's Facility
Physician #1's Address
Street Address

City

State / Province / Region

Postal / Zip Code
Attending Physician #2
Leave blank if only 1 Physician
Title, First & Last Name
Physician #2's Phone Number ### ###-####
Physician #2's Fax Number ### ###-####
Physician #2's Facility
Physician #2's Address
Street Address

City

State / Province / Region

Postal / Zip Code
Consultation Information
Diagnosis Code(s)
Procedure Code(s)
Questions, Comments, Additional Info, etc.
Upload Supporting Files

File Types: DOC, DOCX, JPEG, JPG, PDF, or TXT

Size Limit: 10MB

Upload files one at a time by browsing for a file and choosing Upload File. You may then Browse for another file and repeat up to a limit of 10 files.

11.20.2024.10.48

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Request for Medical Case Management

Requester Information

Patient Information

Provider Information

Consultation Information