carenavApp:: Add New Requests

Add New Request

Call in Information

Call in Person

Employer

no result found

Type of Call

Regarding

Created by

Created Date

Assigned To

Request Status

Patient Information

Name

Gender

DOB

Phone

Address Line 1

Address Line 2

Individual Max Deductible

Individual Used Deductible

Travel Distance

Preferred communication

Special Considerations

Employee Information

Name

Gender

DOB

Phone

Address Line 1

Address Line 2

Insurance ID

Employee ID

Primary Network

Secondary Network

Plan

Plan Type

Family Max Deductible

Family Used Deductible

Employee Information

Diagnosis

Ordering Physician Designation

Ordering Provider Name

Order Entered by

Service Information

Do you have a referring Physician?

Name

Fax

Phone

Procedure 1

Procedure 2

CPT Code

What's Included

Description of Services

Network Option(s)

Add New Option

Service Option

Provider Info

Provider Address

Cost Difference

Delete

State Avg

Est. Cost

Incentives

Cost Saving

Service Option

Provider Info

Provider Address

Cost Difference

Delete

State Avg

Est. Cost

Incentives

Cost Saving

Notes & Histroy

Add New Notes

Created Date

Created By

Assigned To

Request Status

Notes

Action

11/09/2016

Tamra V.

Ojash

Open

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