REQUEST FOR PRE-ADMISSION CERTIFICATION

Step 1 of 4

Dear Physician: If a planned inpatient admission is scheduled for this patient, please complete the information on this form. You may mail this form to the address above, via fax to 305-384-7059 in the continental US or from overseas. This form must be received by PayerFusion Holdings, LLC at least two working days (weekends and holidays excluded) prior to the date of the planned admission.

Section I

Admitting Physician:

(Last, First, MI)

Physician’s Address:

Street Address

Physician’s Address:

City

Physician’s Address:

State

Physician’s Address:

Zip

Physician I.D. #:

Phone #:

Patient’s Name:

(Last, First, MI)

Patient’s Date of Birth:

Patient’s Sex:

Male

Female

Is Insured a PPO Member:

Yes

Patient’s Relationship to Insured:

Self

Spouse

Child

Other

Insured’s I.D.#

Phone #:

Insured’s Address:

Street Address City State / Province / Region ZIP / Postal Code

Group Name:

Group #:

Hospital Name:

Hospital Code:

Hospital Address:

City State / Province / Region ZIP / Postal Code

Scheduled Admission Date:

Description

ICD-9-CM Code

Admitting Diagnosis:

ICD-9-CM Code

Other Relevant Diagnosis:

Other Relevant Diagnosis 2

Other Relevant Diagnosis 3

Other Relevant Diagnosis 4

Other Relevant Diagnosis 5

Other Relevant Diagnosis 6

CPT-4 Code

Date Scheduled

Scheduled Procedures:

CPT-4 Code

Date

Scheduled Procedures 2

CPT-4 Code 2

Date

Section II

Please list pertinent clinical information for this admission as follows:

Physical findings (recent onset)

Relevant past medical history

Relevant radiological, laboratory or EKG findings

Current medications

Other relevant factors affecting this admission

Section III

Please list treatment plan if this admission is not for procedures previously identified in Section I: