Single case agreement sample letter 2026

1. Click ‘Get Form’ to open the single case agreement sample letter in the editor.
2. Begin by filling out the MEMBER INFORMATION section. Enter the member's name, date of birth, and member ID number. Indicate if the member is a Medicare recipient by selecting 'Yes' or 'No'.
3. Next, move to the PROVIDER INFORMATION section. Fill in the provider's name, licensure type, date of birth, social security number, and any applicable group name or tax ID.
4. Complete additional fields such as rendering provider NPI, Medicaid number, phone number, Medicare number (if applicable), fax number, point of contact name, email address, and mailing address.
5. In the DATES OF SERVICE section, specify the requested procedure codes and diagnosis code relevant to the services being requested.
6. Provide a rationale for the single case agreement by checking appropriate boxes under SINGLE CASE AGREEMENT RATIONALE based on your situation.
7. Ensure all fields are completed as indicated. Once finished, download any required documents like W9 and proof of insurance before submitting.
8. Finally, fax your completed form along with additional documents to Cenpatico Single Case Agreements at 866.374.1576.

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