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PROVIDERS: PLEASE FAX A COPY OF THE ID CARD AND CLINICAL INFORMATION FOR THIS CASE TO 312-236-8547. PLEASE INCLUDE WEB REFERENCE NUMBER ON COVERSHEET. FAILURE TO FAX OVER INFORMATION REQUIRED WILL RESULT IN DELAY OR POTENTIAL CLOSURE OF REVIEW PROCESS. YOU MAY ALSO SEND A HIPAA-COMPLIANT EMAIL TO UR@MEDICALCOST.COM IN LIEU OF FAX.

Utilization Review Precertification Request

PLEASE USE THE TAB BUTTON OR MOUSE TO MOVE BETWEEN FIELDS ON THE SCREEN - PRESSING ENTER WILL SUBMIT THE REQUEST

(*Required Fields: Your Precertification Request cannot be submitted unless these fields are completed.*)

Contact Information:

Your Name First/Last: (*Required Fields*)

Telephone Number: (*Required Fields*)
home work other

Your Company:

Type of Precert Requested: (*Required Fields*)
Hospital Precert (Please Select below if Hospital is Checked)
Elective Urgent Emergency 23 hr. Observation


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Surgical/Diagnostic Procedures (Please Select below if Surgical/Diagnostic is Checked)
Inpatient Outpatient Office

Other Precert

Please Specify Treatment of Care if Other Precert Selected:

Patient Information:

Patient Name First/Last: (*Required Fields*)

Patient DOB: (*Required Fields*)

Gender:
Male Female

Patient Telephone Number: (*Required Fields*)
home work other

Relationship to Insured: (*Required Fields*)
Spouse Child Self

Insured Information:

Insured Name First/Last: (*Required Fields*)

SSN or Unique ID: (*Required Fields*)

Insured Address: (*Required Fields*)

City/State/Zip: (*Required Fields*)

Insured Telephone Number: (*Required Fields*)
home work other

Insured Employer: (*Required Fields*)

Physician Information:

Physician Name First/Last: (*Required Fields*)

Physician Address: (*Required Fields*)

City/State/Zip: (*Required Fields*)

Physician Telephone Number: (*Required Fields*)
home work other

Physician Specialty:

Facility Information:

Facility Name:

Facility Address:

City/State/Zip:

Facility Telephone Number:
home work other

Medical Information:

ICD10 Diagnosis Code: (*Required Fields*)

CPT Procedure Code: (*Required Fields*)

Cost of Planned Procedure(s)/Treatment:

Admission Date: (*Required Fields*)

Discharge Date:

ICD10 Diagnosis Code Description:

Please add Procedure Codes and Description in Field Below:

CPT Procedure Code Description: (*Required Fields*)

Other Information:

PROVIDERS: PLEASE FAX A COPY OF THE ID CARD AND CLINICAL INFORMATION FOR THIS CASE TO 312-236-8547. PLEASE INCLUDE WEB REFERENCE NUMBER ON COVERSHEET. FAILURE TO FAX OVER INFORMATION REQUIRED WILL RESULT IN DELAY OR POTENTIAL CLOSURE OF REVIEW PROCESS. YOU MAY ALSO SEND A HIPAA-COMPLIANT EMAIL TO UR@MEDICALCOST.COM IN LIEU OF FAX.