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Collects member identity details (name, insurance ID, DOB, address), service and provider information (PCP, requesting/provider facility, TIN/NPI), type of care selections, ICD-10 and CPT codes, requested items and services, and comments. Includes in-network benefits and expedite request criteria with required supporting documentation, plus mandatory contact information fields for name, phone, and 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review?",{"text":117,"@type":109},"Expedite applies when the member’s life, health, or ability to regain maximum function is in serious jeopardy if a standard-time determination is not made, and the request must include supporting documentation and an explanation required field.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288902,1790955661,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},1099514067438,"https://ap-avatar.wpscdn.com/avatar/100002539ee87300030?x-image-process=image/resize,m_fixed,w_180,h_180&k=1780474512215547542","| For High Tech\u003Cbr>Imaging | Carelon Medical Benefits Management | Phone: 800-920-1250 | [http://carelon.com](http://carelon.com |)[ |](http://carelon.com |)\u003Cbr>[For Registration](For Registration:  Providence PIN #: 045-83169)[: ](For Registration:  Providence PIN #: 045-83169)[ P](For Registration:  Providence PIN #: 045-83169)[rovidence PIN \\#: 045-83169](For Registration:  Providence PIN #: 045-83169) |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| Member Information |  |  |  |  |  |  |\n| Last Name: |  |  | First Name: |  |  |  |\n| Insurance ID \\#: |  |  | DOB: |  |  |  |\n| Address: |  |  | Date of Service: |  |  | Date Span Requested: |\n| Primary Care Physician (PCP): |  |  |  |  |  |  |\n| Requesting Provider: |  |  |  |  | TIN\\#: |  |\n| Address: |  |  |  |  | NPI\\#: |  |\n| Servicing Provider: |  |  |  |  | TIN\\#: |  |\n| Address: |  |  |  |  | NPI\\#: |  |\n| Servicing Facility: |  |  |  |  | TIN\\#: |  |\n| Address: |  |  |  |  | NPI\\#: |  |\n| Type of Care:\u003Cbr>☐ Elective Inpatient Admit | ☐ Elective Outpatient Surgery | ☐ Office Surgery | ☐ Outpatient Diagnostics | ☐ ASC |  |  |  |  |  |  |\n| ICD-10 Code(s): |  | CPT Code(s): |  | Requested Item/Service: |  |  |\n| Requested Services:\u003Cbr>☐ Office Visits, \\# of visits:   ☐ Surgery | ☐ Diagnostic | ☐ Facility Auth Only | ☐ DME | Other   |  |  |  |  |  |  |\n| Comments |  |  |  |  |  |  |\n| In-Network Benefits: Request must include supporting documentation to substantiate why services cannot be provided by an in-network provider/facility. ☐ New Patient ☐ Established Patient | Date last seen\u003Cbr>Explanation Required: |  |  |  |  |  |  |\n| Expedite-defined as member’s life, health or ability to regain maximum function is in serious jeopardy if determination is not made in the standard time frame. Request must include supporting documentation to substantiate an expedited review.\u003Cbr>Explanation Required: |  |  |  |  |  |  |\n| **REQUIRED** Contact Information: |  |  |  |  |  |  |\n| Name: |  |  | Phone: |  |  | Fax: |","cbCaifVcqtUmsL2w","https://ap.wps.com/l/cbCaifVcqtUmsL2w","pdf",213877,"English","# Member Information\n# Type of Care and Requested Services\n# In-Network Benefits and Expedite Criteria\n# Required Contact Information","[{\"question\":\"What member and request details are required on the form?\",\"answer\":\"The form collects last name, first name, insurance ID, DOB, address, and the date of service with date span requested, along with service/provider details such as PCP, requesting provider, and servicing facility.\"},{\"question\":\"Which coding fields does the form include?\",\"answer\":\"It includes fields for ICD-10 code(s) and CPT code(s), plus requested item/service and requested services checkboxes.\"},{\"question\":\"What are the conditions for an expedited review?\",\"answer\":\"Expedite applies when the member’s life, health, or ability to regain maximum function is in serious jeopardy if a standard-time determination is not made, and the request must include supporting documentation and an explanation required field.\"}]","PA_Fax_Form - Registration Fax Form | PDF",1789634187]