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Our Company
Our Services
Contact Us
International Centers of Excellence
Provider Search
PayerFusion Forms

Treatment plan

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Treatment plan

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To:

Date:

MM slash DD slash YYYY

From:

Phone Number:

Provider Name:

Fax Number:

Patient's Full Name:

Date of Birth:

MM slash DD slash YYYY

Member ID Number:

Untitled

Urgent

Please Reply

Please Comment

Please Review

For Your Information

Please provide the following information to assist us in being able to expedite your request. In addition, remember to forward any referrals and all supporting records related to this episode of care (*are mandatory).

DOS:(Required)

*PROVIDER NAME:(Required)

TAX ID:(Required)

NPI (if applicable):(Required)

ICD-10:(Required)

ICD-10

ICD-10:

Estimated Charges:

CPT:(Required)

CPT:

CPT:

CPT:

CPT:

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

Yes

No

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

Yes

No

For Physical Therapy Cases please provide:

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

No

Independent facility (Yes or No):(Required)

Yes

No

If you have any questions regarding this request please call (866) 752-8881 or email corpcases@payerfusion.com. Please submit this form via fax to: 305-384-7059

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