Admission Notification Form PBCBS AK - premera.com 2026

1. Click ‘Get Form’ to open the Admission Notification Form in our editor.
2. Begin by filling in the required fields, starting with the *Member ID* and *Patient name*. Ensure accuracy as this information is crucial for processing.
3. If applicable, provide details for maternity admissions, including the birth mother’s name and baby gender. This section is essential for newborn notifications.
4. Complete the *Facility Contact* section, entering the contact name, facility name, phone number, address, and fax number. All fields marked with an asterisk (*) are mandatory.
5. In the *Utilization review information* section, input your TIN # and phone number. Select the type of admission by checking one box from options like Acute Inpatient or Emergency.
6. Fill in additional details such as admit date, discharge date, ICD diagnosis code, and admitting physician's name. Ensure all relevant medical codes are accurate.
7. Once completed, review all entries for accuracy before submitting. Fax the form to 888-742-1487 along with any necessary medical records.

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