Patient First Name *

Patient Last Name *

Parent Full Name *

Parent Phone # *

Insurance Carrier

Has a VOB been complete for this patient by IFC? *

YES

Please select which facility you are requesting pre-authorization for:

FACILITY NAME *

Where is the patient coming from? *

Hospital

Clinical Facility

Home

Non-Clinical Facility

*If patient is coming from anywhere but home, please input facility name and any specific information about the program here:

Is the patient's application filled out? *

YES

Admission Date: *

Please attach any and all clinical documentation here. *

Is patient Insurance DEPENDANT ONLY? *

Please list ALL current diagnosis: *

Does this patient have a state appointed/Medicaid Case Worker? *

Yes

If yes, please give us their name, any contact information you have for them, and any other information you have below:

Please list all CURRENT and SUSPECTED diagnosis: *

Please use the box below to provide any additional information we need for this pre-authorization request: *

Please hit the submit button below so your request can be fulfilled.