Outpatient Request Form – Fill Out and Use This PDF

Our Outpatient Request Form makes planning treatment and filing paperwork much simpler for your healthcare provider. With this one form, you can clearly indicate which procedures or type of care you need. This form also allows physician offices to more easily capture important medical information and patient needs typically associated with an outpatient visit. Filling out this form ahead of time is a great way to ensure that your visit goes as smoothly as possible by having all important information filled out and ready to go. With the Outpatient Request Form, we aim to make sure that your healthcare experience is professional, safe, and straightforward!

Outpatient Request Form PDF Details

Many healthcare organizations require patient requests to be submitted with a formal request form. Outpatient request forms are an essential component of providing quality care and ensuring accuracy in medical files while preserving patient confidentiality. This blog post will provide information on the importance of outpatient request forms, outline the elements they typically include, and discuss tips for properly filling out the forms. With this information, healthcare professionals can ensure their organization is providing services that meet all relevant standards, as well as maintain proper documentation for any treatments or referrals provided to each individual patient.

Question	Answer
Form Name	Outpatient Request Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	tricare outpatient request form, health net outpatient request form, outpatient request form health, hnfs request form online

Form Preview Example

Outpatient Request Form

		FAX TO: 1-888-299-4181

Request Priority: Care must be rendered:	within 72 hours	outside 72 hours

IBH

Service Type

Specialty Referral/Global Maternity

Physical or Occupational Therapy

OP Behavioral Health

OP Medical Care/Procedure

DME/Radiology

Speech Therapy

Outpatient Surgery

IV Therapy/Home Health

Adjunctive Dental

Hospice/Respite Care

Inpatient Physical Health

Inpatient Behavioral Health

PHP

Requesting Provider Information

Requesting Provider Telephone Number: (			)	-
Requesting Provider Fax Number:		(	)	-
Contact Name:

Requesting Provider/Facility Name:
Physician State License #:
Physician State License #:

Requesting Provider NPI #:

Billing Tax ID #:

Correspondence Preference:	Fax		US Mail
Is the Requesting Provider Performing the Service?				Yes	No
Is this a continuation/ extension of services?				Yes	No
Anticipated Date of Service:	/		/

Patient Information (Please complete all fields)

Sponsor SSN:

Patient Name (Last, First, MI):

Patient Date of Birth:

Patient Address:

ZIP Code

Street

City

State

Patient Home Phone:

(

)

Other Health Insurance:

Servicing Provider Information (Complete all applicable fields)

Specialty:

Phone:

Servicing Provider Name:

(

)

Address:

Fax:

(

)

Facility Name (If Applicable):

Phone:

(

)

Address:

Fax:

(

)

Requested Service Information (Complete as many sections as required)

Diagnosis:

Code:

Description:

Code:

Description:

Service 1:

CPT/HCPC/NDC Code:

Description:

Number of Visits:

Frequency:

Duration:

If DME:

Purchase

Rental

If Global Maternity – Due date

Service 2:

CPT/HCPC/NDC Code:

Description:

Number of Visits:

Frequency:

Duration:

If DME:

Purchase

Rental

Service 3:

CPT/HCPC/NDC Code:

Description:

Number of Visits:

Frequency:

Duration:

IF DME:

Purchase

Rental

Attach Clinical History/previous treatment/plan of treatment, supporting lab/X-ray reports, etc., if necessary.

Confidentiality Note: This facsimile and documents accompanying this facsimile transmission may contain confidential information. The information is intended only for the use of the individual or entity name above. If you are not the intended recipient, or the person responsible for delivering it to the intended recipient, you are hereby notified that any disclosure, copying, distribution or use of the information contained in this transmission is strictly PROHIBITED. If you have received this transmission in error, please notify the sender immediately by telephone or by return FAX and destroy this transmission along

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Outpatient Request Form – Fill Out and Use This PDF

Outpatient Request Form PDF Details

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