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Pacificare Form – Fill Out and Use

Pacificare Form is a PDF document that all nurses must fill out. It's used to keep track of all the medications you have administered.

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Pacificare Prior Authorization Form Details

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

STAT

		TREATMENT AUTHORIZATION FORM			From:
		TREATMENT AUTHORIZATION FORM			Name:
					Name:

					Address:
Prior Auth. Fax #		(800) 457-3828	PLAN TYPE:	Commercial
Prior Auth. Fax #		(800) 457-3828	PLAN TYPE:	Commercial	City, State, Zip:
Home Health Auth. Fax #		(800) 207-1833		Secure Horizons
				Secure Horizons	Phone:
					Phone:

DME Auth. Fax #		(800) 710-8812			Fax Back No.:

		THIS PORTION TO BE COMPLETED BY PHYSICIAN

Patient Name:				Primary Care MD:

Address:				Refer To:

City:			State:	Specialty:

Zip:		Home #:		Address:

Sex:	DOB:		Age:	City:		State:		Zip:

Member ID#:				Office #:			Office Fax #:

Type of Service: Inpatient

Outpatient

Home Health DME Initial Visit

CLINICAL HISTORY & PHYSICAL FINDINGS

Return Visit

Other

REASON FOR REFERRAL: Consultation	Testing	Follow-up	Procedure	No. of Visits Requested:

	DIAGNOSIS				ICD-9 CM CODE:

1.

2.

EVALUATION & TREATMENT PLAN					RVS/CPT – 4 CODE:

1.

2.

3.

REQUESTED FACILITY

Accident: Yes

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: ______________________________
Facility Contracted		Yes	No
________	Authorized		Date _____________		Initials _______	CPT Codes Authorized/No. of Visits _________________________
________	Pended		Date _____________		Initials _______	Reason _______________________________________________
________	Denied		Date _____________		Initials _______	Reason _______________________________________________
________	Modified		Date _____________		Initials _______	Reason _______________________________________________
						SE 7-26-00

Pacificare Form – Fill Out and Use

Pacificare Prior Authorization Form Details

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