PRECERTIFICATION REQUEST

Precertification (English)

QHM - Precert (English)

Please provide the following information so that we may contact you with any questions AND to send authorization.

First Name

Last Name

Phone

Fax for Authorization

Please complete as much of the following information as possible.

Patient First Name

Patient Last Name

Patient Date of Birth

Patient ID number

Provider Name

Provider Tax ID

Date of Service

Length of Stay

Please provide all applicable ICD / CPT codes below. Press the "+" icon to enter multiple sets of codes.

Diagnosis Codes

ICD 10 Code	CPT / HCPCS Code

Additional Information

Please scan and upload all medical notes (individual file size limit is 10MB)

Choose up to 4 files (images, documents, PDFs or ZIP files)