Ect Pdf 108778 | Ca Ect Auth Request Form

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135x Filetype PDF File size 0.15 MB Source: www.magellanprovider.com

File: Ect Pdf 108778 | Ca Ect Auth Request Form

Electroconvulsive Therapy (ECT) Request Form Submit fax to 1-888-656-3510 Date of Request: Initial: Concurrent: Member Information Member Name: _ DOB: Member ID: Subscriber Name: Subscriber ID: Group #: Provider Information ...

Filetype PDF | Posted on 27 Sep 2022 | 2 years ago

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...Electroconvulsive therapy ect request form submit fax to date of initial concurrent member information name dob id subscriber group provider facility npi address phone credentials medical practitioner performing history past yes no if was within months s n a frequency authorization for type unilateral bilateral cpt code planned start end total sessions requested response most recent session length convulsion current diagnoses icd description behavioral health treatment level care select all that apply inpatient rtc php iop op admissions dates service medications dosage title print signature in california magellan does business as human affairs international inc and or services employer rev...

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Category: Uncategorized / Uncategorized
Posted on: 27 Sep 2022 | 2 years ago
Tag: download pdf, auth, request, form,
Filetype: PDF
File size: 0.15 MB
Views: 135x
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