Pre-Service Non-Urgent Standard (Physician Signature NOT Required) 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Demographics' section. Enter the patient's name, member ID, street address, city, state, date of birth, and phone number.
3. Next, complete the 'Referring Provider Information' section. Input the provider's name, address, city, state, provider number, zip code, phone number, fax number, and specialty.
4. In the 'Referred To Physician/Facility/Provider Information' section, provide details about the referred physician or facility including their name and address.
5. Fill in the 'Request Information' section with dates of service and diagnosis codes. Include any relevant CPT codes and descriptions as well as third-party liability information if applicable.
6. Complete the 'Test Information' section by detailing clinical history and specifying the test name along with testing lab information.
7. Finally, ensure all sections are filled accurately before submitting. You can then download or share your completed form directly from our platform.

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