Read CIGNA Request Form >4-7-2009 text version

CIGNA Therapy Fax Request

60941

PLEASE USE THIS FORM FOR CIGNA MEMBERS

Fax Date: ____________# of Pages Faxed: _______ Please fax to OrthoNet at: (888) 230-6265

Facility Name

THERAPY PROVIDER INFORMATION

Street Address

City

State

Zip

Telephone Number

Return Fax Number

(

)

First Name

-

(

)

-

National Provider Identifier (NPI)

PATIENT INFORMATION

Facility NPI Number Individual NPI Number

Last Name

OrthoNet / CIGNA Provider ID Number

Date of Birth

(Note: 5 digit ID#'s should be preceded with "00")

/

Month Day

/

Year

REQUEST INFORMATION

Request for: Therapy Visits Pre-Certification Other Procedure: ________________________ Is this request for post-operative therapy visits?

Alpha Prefix

Patient ID Number

1

1

1

1

1

1

1

1

1

1

1

Yes

No

Service Type

Physical Therapy Occupational Therapy Splint

2

2

2

2

2

2

2

2

2

2

2

3

3

3

3

3

3

3

3

3

3

3

4

4

4

4

4

4

4

4

4

4

4

Initial Evaluation Date

5

5

5

5

5

5

5

5

5

5

5

6

6

6

6

6

6

6

6

6

6

6

/

Month Day

/

Year Requested # of Visits

7

7

7

7

7

7

7

7

7

7

7

8

8

8

8

8

8

8

8

8

8

8

Diagnosis Code (i.e. 8430 or V4365)

9

9

9

9

9

9

9

9

9

9

9

0

0

0

0

0

0

0

0

0

0

0

Instructions:

1. 2. 3. 4. Use this form as a Fax Cover Sheet and send all supporting clinical data with this request. Please ensure that this form is a DIRECT COPY from the MASTER. Please PRINT, in black ink, one character per box for ALL requested information and completely fill in each circle that represents the corresponding NUMBER entry where applicable. For assistance in completing this form, please call OrthoNet Provider ServicesToll Free at (866) 874-0727.

Reset

For Internal Office Use Only

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60941

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Copyright 2009 OrthoNet, LLC

Information

CIGNA Request Form >4-7-2009

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