Facility Based Treatment Form | Healthy Blue - Healthy Connections Form Resource Center

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Facility-Based Treatment
Facility-Based Treatment Form

Facility-Based Treatment Form

Facility Information
Patient Information
Clinical Information

Instructions

Please indicate whether you are requesting certification for initial or continued stay treatment. Fields marked with an asterisk are required. The certification is not valid until a certification number is issued.

Please indicate if this is:

An Initial Review

A Continued Review

Step One - Facility Information

Facility's Name

Attending MD's First Name

Attending MD's Last Name

Phone Area Code () First Three Digits - Last Four Digits

Fax Area Code () First Three Digits - Last Four Digits

Facility's NPI

UR Name

UR Contact Number Area Code () First Three Digits - Last Four Digits

UR Fax Number Area Code () First Three Digits - Last Four Digits

Facility's Physical Address

Address 1

Address 2

ZIP Code

City

Authorization Email Address

Your Name

Your Phone Area Code () First Three Digits - Last Four Digits