Initiate Precertification


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Patient Information
Service Information
Treatment/Service/Supply
Physician Information
Facility Information
Please call (317) 655-4500 for Emergency Medical Evacuation requests. Do not use this form for Evacuation requests. You will be notified upon receipt of this precertification. Precertification is not a guarantee of payment nor is it a denial. It remains the insured person's responsibility to verify benefits. All conditions and provisions of the insured person's certificate of insurance apply.

Is this Precertification Initiation Form being submitted by the Provider?
 
* Denotes a required field
 
Patient Information
 
Name of Insured*
Certificate / Group Number*
Date of Birth*
  
Country*
 
Address*
 
Address 2
City*
State or Province
 (US & Canada only)
Postal Code
 (US & Canada only)
Region
Phone Number*
Fax Number
E-mail Address*
 
How would you prefer to receive the Precertification letter?
 
If additional information is needed to complete the Precertification,
is it okay to contact you by e-mail?

 
Would you like a Verification of Benefits to be forwarded to you
within two business days via e-mail?

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