Enteral Therapy Precertification Worksheet - unicarestateplan 2026

1. Click ‘Get Form’ to open the Enteral Therapy Precertification Worksheet in the editor.
2. Begin by entering the patient's name, date of birth, and member ID in the designated fields at the top of the form.
3. Fill in the provider's information, including name, phone number, fax number, and address. This ensures that all communication is directed correctly.
4. Next, provide details about the ordering physician. Include their name, phone number, fax number, and address for accurate processing.
5. Indicate where the patient resides and where treatment will occur by selecting from the options provided or specifying other locations as necessary.
6. Complete the diagnosis section with relevant information and ICD-10 code to support medical necessity for enteral nutrition.
7. List requested services including formula/supply names and codes along with dosage, route, frequency, start date, and stop date.
8. Finally, ensure all signatures are completed before submitting. Once finished, save your document and send it via fax to 800-848-3623.

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