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picture1_Ect Pdf 108373 | Ect Request Form


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File: Ect Pdf 108373 | Ect Request Form
electroconvulsive therapy ect ect request form provider must call bcbsil at 800 851 7498 to check benefits for initial services providers can complete this form print and fax to bcbsil ...

icon picture PDF Filetype PDF | Posted on 27 Sep 2022 | 3 years ago
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                                                                                                      Electroconvulsive Therapy (ECT) 
                                                                                                                 ECT REQUEST FORM
                                            Provider must call BCBSIL at 800-851-7498 to check benefits. 
                          For initial services, providers can complete this form, print and fax to BCBSIL at 877-361-7656, 
                                            or access the Availity® Authorizations tool and submit online.
       Date______________
         Check One:  c Initial Request    c Concurrent    c Discharge 
         Patient Name____________________________________________________        Patient Date of Birth__________________________________________
         Subscriber Name________________________________________________         Subscriber ID_____________________  Group____________________
         Facility/Provider Name _______________________________________           NPI_________________________________________________________________
         Address_________________________________________________________ _ ___   City___________________________________State_____ Zip_______________ 
         Primary MD Full Name _____________________________________________       MD NPI____________________________________________________________
         Address_____________________________________________________________     City___________________________________State_____ Zip_______________
         UR/Contact Name__________________________________________________        Phone _____________________ Ext. _________  Fax ____________________
         ECT History: Has patient had ECT in the past?   c Yes     c No           Has patient had ECT in the last 6 months?   c Yes       c No 
         Past Frequency?______________________________ (x per week/month)         Brief details of ECT to date:  ______________________________________
         Is this a transition after IP ECT?   c Yes     c No 
         Current ECT plan-frequency_________________ (x per week/month)           Visits requested (CPT Code):  c 90870   #________       
         Requested ECT auth start date _______________________________            Tentative end date of treatment:_________________________________
       Current DX — Please list ICD-10 code, Diagnosis Name, Specifier and all Medical Diagnoses
       ICD-10 Code  ___________________ DX Name  ___________________________________ Specifier  _________________________________________
       ICD-10 Code  ___________________ DX Name  ___________________________________ Specifier  _________________________________________
       ICD-10 Code  ___________________ DX Name  ___________________________________ Specifier  _________________________________________
       ICD-10 Code  ___________________ DX Name  ___________________________________ Specifier  _________________________________________
       ICD-10 Code  ___________________ DX Name  ___________________________________ Specifier  _________________________________________
       Medications (Dosages)
       Current Clinical Presentation/Risk Factors (Substance abuse: Include last date of use) 
       Previous MH/CD Treatment 
       Current Treatment Goals 
       Discharge Plan/Summary 
       My signature confirms that I am providing the requested services:
       Signature ___________________________________________________________ Date _________________
       Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical 
       professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided 
       by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. 
       A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
       03103.0520
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...Electroconvulsive therapy ect request form provider must call bcbsil at to check benefits for initial services providers can complete this print and fax or access the availity authorizations tool submit online date one c concurrent discharge patient name of birth subscriber id group facility npi address city state zip primary md full ur contact phone ext history has had in past yes no last months frequency x per week month brief details is a transition after ip current plan visits requested cpt code auth start tentative end treatment dx please list icd diagnosis specifier all medical diagnoses medications dosages clinical presentation risk factors substance abuse include use previous mh cd goals summary my signature confirms that i am providing trademark llc separate company operates health information network provide electronic exchange professionals provides administrative makes endorsement representations warranties regarding any products provided by third party vendors such as if y...

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