Member Information:

Member ID: Member Name:

Requesting Physician:

NPI#: Name: Address: Phone Number: UR Phone: URUM Fax: Email:

Attending Physician:

NPI#: Name: Address: Phone Number: Email:

Facility:

NPI#: Name: Address: Phone Number: UR Phone: Fax Number: Email:

Admission Information:

Number of Days/Units requested: Number of Days/Units Approved: Requested Date of Admit: Type of Admission: Type of Authorization: Type Code Description Primary Present on Adm NDC Print   Close Contact Customer service