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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Oregon Division of Financial Regulation
December 30, 2024 11:24 amMailing: PO Box 14480 Salem, OR 97309
Washington State Office of the Insurance Commissioner
December 30, 2024 11:23 amMailing address: P.O. Box 40255 Olympia, WA 98504-0255
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