Date of Request - MemorialCare - memorialcare 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Date of Request' at the top of the form. This is essential for tracking your request.
3. Select the appropriate request type: Routine, Urgent, or Emergent. Each option has specific processing times, so choose based on clinical need.
4. Fill in the 'Requesting Provider/Group Name', 'Specialty', and contact details including address and phone number.
5. Enter patient information, including name and date of birth. Ensure accuracy for proper identification.
6. Complete the 'PCP' section with the primary care provider's name and relevant visit dates.
7. List services requested by entering CPT codes and descriptions, along with ICD-10 codes as necessary.
8. If applicable, provide additional obstetrical care information such as LMP date and ultrasound details.
9. Review all entries for accuracy before submitting your request via fax to the appropriate office listed on the form.

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