Pacificare Health Systems is a company that offers health insurance and other health benefits to individuals, families, and businesses. The company has several different plans available, and it can be difficult to determine which plan is best for you or your organization. Pacificare Form is an online tool that can help you make this decision. With Pacificare Form, you can compare the features of different plans, find out if you are eligible for discounts, and even apply for coverage. This tool makes it easy to find the right plan for your needs.
In the listing, there's some good information about the pacificare form. You will have the estimated time it'd require you to complete the form plus some further details.
| Question | Answer |
|---|---|
| Form Name | Pacificare Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | aarp secure horizons authorization pdf, pacificare prior authorization form, uhc pacificare secure horizon preauthorization request form, securehorizons authorization form |
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ROUTINE |
URGENT |
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TREATMENT AUTHORIZATION FORM |
From: |
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Name: |
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Address: |
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Prior Auth. Fax # |
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(800) |
PLAN TYPE: |
Commercial |
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City, State, Zip: |
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Home Health Auth. Fax # |
(800) |
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Secure Horizons |
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Phone: |
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DME Auth. Fax # |
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(800) |
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Fax Back No.: |
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THIS PORTION TO BE COMPLETED BY PHYSICIAN |
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Patient Name: |
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Primary Care MD: |
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Address: |
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Refer To: |
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City: |
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State: |
Specialty: |
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Home #: |
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Address: |
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Sex: |
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DOB: |
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Age: |
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Member ID#: |
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Office #: |
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Office Fax #: |
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Type of Service: Inpatient |
Outpatient |
Home Health DME Initial Visit
CLINICAL HISTORY & PHYSICAL FINDINGS
Return Visit
Other
REASON FOR REFERRAL: Consultation |
Testing |
Procedure |
No. of Visits Requested: |
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DIAGNOSIS |
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1. |
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2. |
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EVALUATION & TREATMENT PLAN |
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RVS/CPT – 4 CODE: |
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2. |
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3. |
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REQUESTED FACILITY
Accident: Yes |
No |
Occurrence: Home |
Work |
Auto |
Other |
Other Insurance: _____________________________________________________________________________
MD Signature: ___________________________________________ Date: ____________________________
*** NOTE: The member has the right to appeal denial of services through PacifiCare/Secure Horizons
THIS PORTION TO BE COMPLETED BY UR ONLY. THIS REFERRAL FORM DOES NOT GUARANTEE ELIGIBILITY.
PLEASE CHECK ELIGIBILITY PRIOR TO PROVIDING SERVICE.
Authorization #:
Date: ________/__________/_________
Provider Contracted |
Yes |
No |
Assigned Length of Stay: ______________________________ |
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Facility Contracted |
Yes |
No |
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________ |
Authorized |
Date _____________ |
Initials _______ |
CPT Codes Authorized/No. of Visits _________________________ |
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Pended |
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Date _____________ |
Initials _______ |
Reason _______________________________________________ |
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Denied |
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Date _____________ |
Initials _______ |
Reason _______________________________________________ |
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Modified |
Date _____________ |
Initials _______ |
Reason _______________________________________________ |
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