Alpha Infusion Management - Infusion Therapy

Alpha Infusion Management
"Infusion Therapy Services Specialist"

RAPID PRE-AUTHORIZATION FORM

Please print out this form on your computer printer, fill it in
and fax it to Alpha Infusion Management at 830-693-3440

ALPHA INFUSION MANAGEMENT
PATIENT REFERRAL FORM

___IV THERAPY ___ENTERAL ___OTHER

REFERRAL TYPE:
_{____ SKILLED NURSING FACILITY}
_{____ HOME HEALTH}
_{____ PHYSICIAN'S CLINIC}
_{____ OTHER (SPECIFY)_______________}

_{ADMISSION TYPE:}
_{____ NEW ____ CHANGE IN SERVICE}
_{______________ START OF CARE DATE}

REFERRAL INFORMATION:
SOURCE NAME:_______________________________ TITLE___________
FACILITY/AGENCY/CLINIC/_____________________________________
ADDRESS:_____________________________________________________
CITY/STATE/ZIP:________________________________________________
PHONE:_____________________FAX_______________________________
PAGER:______________________
RECEIVED BY:__________________________________________________

PATIENT INFORMATION:
NAME:__________________________________ MALE____FEMALE____
SERVICE LOCATION:_____________________DATE OF BIRTH_______
_________________________________________ HEIGHT______________
PHONE:__________________________________WEIGHT:_____________
SOC. SEC#:_______________________________ ALLERGIES:__________
HIC#:____________________________________ _____________________
EMERGENCY CONTACT:__________________ PHONE:______________

DIAGNOSIS: ICD-9 CODES ONSET/E XACER. DATE
1._________________________ _______________ ______________________
2._________________________ _______________ ______________________
3._________________________ _______________ ______________________
4._________________________ _______________ ______________________

INSURANCE INFORMATION:

PRIMARY INSURANCE______________________________________________
INSURED'S NAME___________________________________________________
PT. RELATION TO INSURED__________________________________________
GROUP NAME & #__________________________________________________
POLICY #__________________________________________________________
ADDRESS:__________________________________________________________
CITY/STATE/ZIP:_____________________________________________________
PHONE_____________________________________________________________
CONTACT___________________________________________________________

SECONDARY INSURANCE___________________________________________
INSURED'S NAME___________________________________________________
PT. RELATION TO INSURED__________________________________________
GROUP NAME & #__________________________________________________
POLICY #__________________________________________________________
ADDRESS:__________________________________________________________
CITY/STATE/ZIP:_____________________________________________________
PHONE_____________________________________________________________
CONTACT___________________________________________________________

PHYSICIAN #1 INFORMATION
NAME_______________________________________________________________
ADDRESS____________________________________________________________
CITY/STATE/ZIP_______________________________________________________
PHONE___________________________UPIN#______________________________

PHYSICIAN #2 INFORMATION
NAME_______________________________________________________________
ADDRESS____________________________________________________________
CITY/STATE/ZIP_______________________________________________________
PHONE___________________________UPIN#______________________________

RX ORDERS AND REQUIRED THERAPIES:_____________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

PAYOR:
MEDICARE PART A___ B___ SELFPAY___ DONATED___ MEDICAID___
THIRD PARTY: GROUP INSURANCE___ PRIVATE___ MANAGED CARE___

FAX TO: (830) 693-3440

ALPHA INFUSION MANAGEMENT
407 Main Street, Suite 3
Marble Falls, Texas 78654

(830) 693-2027
(800) 693-4143
Fax: (830) 693-3440