Treatment plan – PayerFusion

Step 1 of 3

To:

Date:

From:

Phone Number:

Provider Name:

Fax Number:

Patient's Full Name:

Date of Birth:

Member ID Number:

Untitled

Urgent

Please Reply

Please Comment

Please Review

For Your Information

DOS:(Required)

*PROVIDER NAME:(Required)

TAX ID:(Required)

NPI (if applicable):(Required)

ICD-10:(Required)

ICD-10

ICD-10:

Estimated Charges:

CPT:(Required)

CPT:

Does Provider Participate in the Aetna Network? (Yes or No):(Required)

Yes

Does Provider Participate in the UnitedHealthcare Network? (Yes or No):(Required)

Yes

How many sessions:(Required)

How many weeks:(Required)

Cost per Session(Required)

Referring Physician:

Medical Necessity:

Does Provider Participate in the Aetna Network? (Yes or No):(Required)

Yes

Independent facility (Yes or No):(Required)

Yes