Medical Rehabilitation Consultants
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Phone: 509-328-9700

Fax: 509-328-9777








Request for Pre-Certification

Attach supporting files using the Upload at the bottom of the page or Fax them to us at 509-328-9777

  • Requester Information

  • Subscriber Information

  • Primary

    Secondary

    Tertiary

    Is this the Patient's Primary(1st), Secondary(2nd) or Tertiary(3rd) insurance provider

  • Self

    Spouse

    Dependant

    How is the Patient related to the Subscriber/Policy Holder

  • Patient Information

  • Male

    Female

  • Pre-Certification Information

  • Inpatient

    Outpatient

  • Physician Information

  • Additional Information

  • Please use the upload below or fax any supporting documents to 509-328-9777 (Attn: Precert Referrals)

  • 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.



     

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