MA Fax Cover Sheet – Peer to Peer Disagreement of Care – Request for Transfer
January 18, 2025 9:00 amPEER TO PEER DISAGREEMENT OF CARE – REQUEST FOR TRANSFER Patient Admitted: On , (“Health... View more
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CA Medi-Cal Fax Cover Sheet – COHS Request for Authorization
December 30, 2024 11:13 amREQUEST FOR AUTHORIZATION At this time, we are requesting authorization to render treatment to... View more
OR HMO Fax Cover Sheet – Request for Authorization of Post-stabilization Services
December 30, 2024 11:08 amREQUEST FOR AUTHORIZATION TO PROVIDE POST-STABILIZATION SERVICES : Federal regulations require that you (1)... View more
OR HMO Fax Cover Sheet – Competent Reviewer Request
December 30, 2024 11:05 amCOMPETENT REVIEWER REQUEST : Oregon law requires that all final recommendations regarding the necessity... View more
OR HMO Fax Cover Sheet – Notification of Disagreement of Care
December 30, 2024 11:01 amNOTIFICATION OF DISAGREEMENT OF CARE On , you notified our facility that further post-stabilization... View more
CA HMO Fax Cover Sheet – Request for Authorization of Post-stabilization Services
December 30, 2024 12:42 amREQUEST FOR AUTHORIZATION TO PROVIDE POST-STABILIZATION SERVICES : Federal regulations require that you (1)... View more
CA HMO Fax Cover Sheet – Notification of Disagreement of Care
December 30, 2024 12:37 amNOTIFICATION OF DISAGREEMENT OF CARE On , you notified our facility that further post-stabilization... View more
WA HMO Fax Cover Sheet – Competent Reviewer Request
December 30, 2024 12:32 amCOMPETENT REVIEWER REQUEST : Washington law requires that there is a right to request... View more
WA HMO Fax Cover Sheet – Request for Authorization of Post-stabilization Services
December 30, 2024 12:26 amREQUEST FOR AUTHORIZATION TO PROVIDE POST-STABILIZATION SERVICES : Federal regulations require that you (1)... View more
VHA Fax Cover Sheet – Request for Authorization of Emergency Services
December 30, 2024 12:20 amREQUEST FOR AUTHORIZATION TO PROVIDE EMERGENCY SERVICES On , you notified our facility that... View more