Pre-Certification Form
Info
RMA Pre-Cert Request
Travel Pre-Cert Request
Pre-Cert Instructions
RMA Pre-Certification Request
Section I -Requester Information (* fields required)
Requester Name *
Phone *
Email *
Fax Number
Section II - General Information
Review Type
Non-Urgent
Urgent
Clinical Reason for Urgency
Request Type
Initial Request
Extension/Renewal/Amendment
Related Previous Pre-Certification ID #
Section III - Patient Information
Patient Full Name
DOB
Gender
Male
Female
Other
Identification #
Section IV - Provider Information
A. Requesting Provider
Name
NPI #
Specialty
Phone
Email
Contact Name
Contact Phone
B. Servicing Facility/Hospital
Servicing Facility/Hospital
NPI #
Specialty
Phone
Email
Primary Care Provider Name
Contact Name
Contact Phone
C. Service or Procedure Information
Planned Service or Procedue
Diagnosis Description (ICD version_10)
Start Date
Procedure Code
Diagnosis Code
End Date
Visit Information
A. General Visit
Inpatient
Outpatient
Provider Office
Observation
Home
Day Surgery
Other
B. Therapy Visits
Physical Therapy
Occupational Therapy
Provider Office
Observation
Home
Number of Sessions
Duration
Frequency
Other
C. Home Health Visits
(MD Signed Order Attached?)
Yes
No
(Nursing Assessment Attached?)
Yes
No
Number of Visits
Duration
Frequency
Other
D.Equipment Needs
DME (MD Signed Order Attached?)
Yes
No
Equipment/Supplies (include any HCPCS Codes)
Duration
E. Imaging Needs
CT Scan
CTA Scan
MRI Scan
MRA Scan
PET Scan
Cardiac Nuclear Scan
Section V - Notes (
max 150 characters
)
Section VI - Attachments
* Clinical documentation indicating medical necessity is required.
Upload Attachments
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