OLYMPUS PRE-CERTIFICATIONS
Please use the form below to submit New Request for pre-certifications for Hospital Admissions, Invasive Surgical Procedures, or Scheduled procedures. For Services occurring within 24 hours, status updates on existing request or Outpatient Services, please contact us using the details found on the member’s insurance card.
PROVIDER REGISTRATION
SUBMITTER INFORMATION
NAME *
PHONE NUMBER *
E-MAIL *

PATIENT INFORMATION
PATIENT NAME *
PATIENT DOB *
POLICY OR ID # *
INSURANCE COMPANY *

Other than Olympus

DATE OF SERVICE *
TBD
DIAGNOSIS / CHIEF COMPLAINT *

Include ICD-10 if known

SERVICES BEING REQUESTED *

Include CPT codes if known

SERVICE TYPE *
Inpatient
Outpatient

WHERE IS THE SERVICE TAKING PLACE?
State: City:

PHYSICIAN INFORMATION
NPI NUMBER:

NAME
PHONE NUMBER
FAX NUMBER
TAX ID #

FACILITY INFORMATION
NPI NUMBER

NAME
PHONE NUMBER
FAX NUMBER
TAX ID #
MEMBER ADMITTED TO A FACILITY
Case Mgmt. / UR Dept. Phone #
Case Mgmt. / UR Dept. Fax #
ROOM #
Medical Record #
COMMENTS