Answer Happy

1 1 1 Print and fill out a TAR for Rose Clarkson Complete a CMS 1500 claim form for Rose Clarkson Complete a Financial Account for Rose Clarkson
PARTNERSHIP HEALTHPLAN of CALIFORNIA PLEASE TYPE YOUR NAME AND ADDRESS HERE NAME AND ADDRESS OF PATIENT PATIENT NAME (LAST, FIRST, M.I.) STREET ADDRESS CITY, STATE, ZIP CODE PHONE NUMBER AREA (PLEASE TYPE) DIAGNOSIS DESCRIPTION: MEDICAL JUSTIFICATION: LINE NO. 1 2 3 4 5 6 AUTHORIZED YES PROVIDER NAME AND ADDRESS NO APPROVED UNITS (FOR PROVIDER USE) SIGNATURE OF PHYSICIAN OR PROVIDER TREATMENT AUTHORIZATION REQUEST FORM (TAR) REQUEST IS RETROACTIVE? YES SEX MEDI-CAL NO NAME/TITLE AGE SPECIFIC SERVICES REQUESTED HOME PATIENT IDENTIFICATION NO. SNF/ICF PROVIDER PHONE NO. FAX # (PLEASE TYPE) PROVIDER NPI# TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS TRUE, ACCURATE AND COMPLETE AND THE REQUESTED SERVICES ARE MEDICALLY INDICATED AND NECESSARY TO THE HEALTH OF THE PATIENT. DATE OF BIRTH CURRENT ICD-CM CODE DATE BOARD & CARE ACUTE HOSPITAL UNITS OF SERVICE OFFICE PARTNERSHIP HEALTHPLAN OF CALIFORNIA 4665 Business Center Drive Fairfield CA 94534 (707) 863-4133 or (800) 863-4144 FAX # (707) 863-4118 www.partnershiphp.org PATIENT'S AUTHORIZED REPRESENTATIVE (IF ANY) ENTER NAME AND ADDRESS: BY: NDC/UPC OR PROCEDURE CODE FOR PHC USE ONLY PROVIDER: YOUR REQUEST IS: DENIED APPROVED AS REQUESTED FROM DATE APPROVED AS MODIFIED DATE COMMENTS/EXPLANATION AUTHORIZATION IS PHC CONSULTANTS NAME QUANTITY FOR SERVICES PROVIDED TAR CONTROL NUMBER SEQUENCE NUMBER REVIEW COMMENT INDICATOR NOTE: AUTHORIZATION DOES NOT GUARANTEE PAYMENT. PAYMENT IS SUBJECT TO PATIENT'S ELIGIBLITY. BE SURE THE IDENTIFICATION CARD IS CURRENT BEFORE RENDERING SERVICE. TO DATE DEFERRED CHARGES
PARTNERSHIP HEALTHPLAN of CALIFORNIA (PLEASE TYPE) PLEASE TYPE YOUR NAME AND ADDRESS HERE NAME AND ADDRESS OF PATIENT PATIENT NAME (LAST, FIRST, M.L.) STREET ADDRESS CITY, STATE, ZIP CODE PHONE NUMBER AREA DIAGNOSIS DESCRIPTION: MEDICAL JUSTIFICATION: NO 1 2 3 4 5 6 PROVIDER NAME AND ADDRESS AUTHORIZED YES NO APPROVED UNITS (FOR PROVIDER USE) REQUEST IS RETROACTIVE ? SIGNATURE OF PHYSICIAN OR PROVIDER TREATMENT AUTHORIZATION REQUEST FORM (TAR) YES SEX NO MEDI-CAL NAME/TITLE AGE SPECIFIC SERVICES REQUESTED HOME PATIENT IDENTIFICATION NO. SNF/ICF PROVIDER PHONE NO FAX# (PLEASE TYPE) PROVIDER NPI TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS TRUE, ACCURATE AND COMPLETE AND THE REQUESTED SERVICES ARE MEDICALLY INDICATED AND NECESSARY TO THE HEALTH OF THE PATIENT. DATE DATE OF BIRTH CURRENT ICD-CM CODE UNITS OF SERVICE BOARD & CARE ACUTE HOSPITAL OFFICE PATIENTS AUTHORIZED REPRESENTATIVE OF ANY) ENTER NAME AND ADDRESS: BY PARTNERSHIP HEALTHPLAN OF CALIFORNIA 4665 Business Center Drive Fairfield CA 94534 (707) 863-4133 or (800) 863-4144 FAX# (707) 863-4118 www.partnershiphp.org NDC/ UPC OR PROCEDURE CODE FROM DATE FOR PHC USE ONLY PROVIDER: YOUR REQUEST IS: APPROVED AS REQUESTED APPROVED AS MODIFIED DATE COMMENTS/EXPLANATION PHC CONSULTANTS NAME QUANTITY DENIED AUTHORIZATION IS VALID FOR SERVICES PROVIDED TAR CONTROL NUMBER SEQUENCE NUMBER NOTE: AUTHORIZATION DOES NOT GUARANTEE PAYMENT, PAYMENT IS SUBJECT TO PATIENT'S ELIGIBLITY. BE SURE THE IDENTIFICATION CARD IS CURRENT BEFORE RENDERING SERVICE. REVIEW COMMENT INDICATOR TO DA DEFERRED CHARGES