Geisinger Health Plan Form A PDF Details

Geisinger Health Plan has announced the launch of its new Form A health insurance plan. The new Form A plan offers comprehensive coverage and a wide range of benefits, making it an excellent choice for individuals and families. Geisinger Health Plan is committed to providing quality, affordable health care coverage, and the new Form A plan is evidence of that commitment. With this plan, members have access to some of the best health care providers in the country. Plus, there are a variety of wellness programs available to help members stay healthy. If you're looking for reliable health insurance coverage, be sure to check out the new Geisinger Health Plan Form A plan.

QuestionAnswer
Form NameGeisinger Health Plan Form A
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesCORF, appropriateness, 2008, Workmans

Form Preview Example

Geisinger Health Plan Outpatient Rehabilitative Therapy Services Network

FORM A

OUTPATIENT REHABILITATIVE THERAPY SERVICES REFERRAL FORM

(New Case)

Phone: (570) 271-5301 Toll Free: 1-800-270-9981 Fax: (570) 271-5302

 

SECTION 1 – (to be completed and faxed upon initial visit) *Required information. Incomplete forms will be returned unprocessed.

Member Information

 

 

Referral Source

*Rehab Provider Facility Name

*Last Name, First Name, MI:

 

Referring Physician

Location:

 

 

 

*First Name, Last Name

*Health Plan Provider #:

 

*DOB:

 

*Phone: ( )

 

*Phone #

 

Address:

 

*Fax: (

)

 

*Fax #:

 

Phone #:

 

*Service Requested

*Site of Service:

 

*GHP ID#:

 

PT

OT

ST

O/P Clinic

SNF

 

 

 

 

 

Hospital

CORF

 

 

 

 

 

Assisted Living Facility

 

 

OTHER INSURANCE INFORMATION: (Workman’s Compensation, Auto Insurance, etc.)

 

Company:

Policy Number:

 

Claim Number:

Date of Accident:

Contact Person:

 

Phone Number:

 

 

 

 

 

 

 

 

 

DIAGNOSIS INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

*ICD-9 CODE:

 

 

*DESCRIPTION:

 

 

 

 

 

 

 

SURGICAL PROCEDURES: (Include Dates)

 

Co-Morbidities:

 

 

 

 

 

 

Psychosocial Factors:

 

 

SECTION 2

Functional level prior to current problem: __________________________________________________________________________

__________________________________________________________________________________________________________

Current Problems/Duration: (Include specific Clinical Information) Or

Eval attached /or 1 visit only Requested

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Goals:

1._____________________________________________________________________________________________________

2._____________________________________________________________________________________________________

3._____________________________________________________________________________________________________

4._____________________________________________________________________________________________________

5._____________________________________________________________________________________________________

Plan of Care: ______________________________________________________________________________________________

Therapist Signature: _____________________________________ Date: _____________________________________________

For Geisinger Health Plan Outpatient Rehabilitative Services Network Only

Authorization #:

# of Approved Visits:

 

Discipline authorized: PT

OT

ST

 

 

 

 

 

 

Approval verifies appropriateness of a level of care and is not a guarantee of payment.

 

 

 

Case Manager Signature: ____________________________________________________

Date: ___________________________

HPCHS02: Form A Sept 2008 Devised: 10/99 Revised: 3/01, 7/06, 2/08, 9/08