Fillable Online RECREATION SUPERVISOR SUMMARY bb - City of ... 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date submitted at the top of the form. This helps track when the request was made.
3. Select whether your request is standard or urgent by checking the appropriate box.
4. Fill in the referring provider's name and contact information, including phone and fax numbers, ensuring accurate communication.
5. Provide member details such as full name, date of birth, and member ID number to identify the patient clearly.
6. List requested services by entering CPT/HCPCS codes along with quantities and procedure descriptions for each service needed.
7. Document diagnosis codes and descriptions accurately to support medical necessity for the requested services.
8. Include information about the requested specialist/provider and facility, ensuring all necessary contact details are provided.
9. Attach any required clinical documents that support your referral request before submitting it through our platform.

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