Case Management
Pre-Certification
Referral Form
Disease Management
Medical Bill Audits
IME's/Peer/Film Review
24-Hour Nurses Line
Pre-Certification: Referral Form

Please fill out the following form. Fields marked with a asterisk (*) are required.

claimant/Patient Information
claimant/Patient Name: *
Address: *
Address:
City: *
State: *
Zip: *
Phone: *
DOB (MM/DD/YYYY): *
Employee SSN: *
Insured/Employee Name: *
Admit / Procedure Date (MM/DD/YYYY): *
Discharge Date:
Patient Status:*
 InpatientOutpatient
*AMCS considers any hospital stay that
is 20 hours or longer to be inpatient.
   
   
Ordering Physician Information
Physician Name:*
Address:*
Address:
City:*
State:*
Zip:*
Phone:*
In Network?* Yes No
Procedure / CPT Code*
Diagnosis / ICD9 code:*
   
Facilty Information
Facilty Name:*
Address:*
Address:
City:*
State:*
Zip:*
Phone:*
In Network?* Yes No
Clinic Information:*
   
 
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