MRC | Precert Referral

Requester Information

Requested By First & Last Name

Employer

E-Mail Address

Phone Number ### ###-####

Fax Number ### ###-####

Insured By

Insurance Group Name or Number

Member/Patient ID

Primary, Secondary, Tertiary or Quaternary

Primary

Secondary

Tertiary

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

Subscriber Name First & Last Name

Patient Relation to Subscriber

Self

Spouse

Dependant

How is the Patient related to the Subscriber/Policy Holder

Patient's Name First & Last Name

Patient's Date of Birth MM / DD / YYYY

Patient Sex

Male

Female

Patient's Address

Street Address

City

State / Province / Region

Postal / Zip Code

Patient's Home Phone ### ###-####

Patient's Cell Phone ### ###-####

Patient's Work Phone ### ###-####

Diagnosis Description

ICD-10 Codes

Procedure Description

CPT Codes

Inpatient or Outpatient

Inpatient

Outpatient

Date of Service MM / DD / YYYY

Days Requested

Facility Name

Facility Tax ID (TIN)

Facility Address

Street Address

City

State / Province / Region

Postal / Zip Code

Facility Phone Number ### ###-####

Facility Fax Number ### ###-####

Physician's Name Title, First & Last Name

Specialty

Physician's Phone Number ### ###-####

Physician's Fax Number ### ###-####

Physician's Address

Street Address

City

State / Province / Region

Postal / Zip Code

Notes, Comments, Questions, etc.

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

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

Request for Pre-Certification

Requester Information

Subscriber Information

Patient Information

Pre-Certification Information

Physician Information

Additional Information