Provider Correspondence Fax Cover Sheet For Medical Printable

Provider Correspondence Fax Cover Sheet To Number of pages (including cover sheet): Patient Name: Date(s) of Service: Claim Number: Tax Identification Number: (on claim) Reason for Correspondence - Corrected Claim: Corrections to be made: - Referral Information from (claims processed with Point of Service Option) - Duplicate Review – Supporting medical documentation for services denied as a Duplicate - ClaimCheck Review – Supporting medical documentation for services denied per Claim Appeal Request - Other: Please use the appropriate secure FAX number from the list below: Routine Correspondence: Save time as a registered member of my business online, anytime, day or night You can view claim status, authorization/referral status, PCM name, eligibility, cost-share, copay and deductible information.