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Transplant Benefit Verification FAX Request Form - CONFIDENTIALTo submit a Benefit Verification request, please complete the following information and fax all related clinical information to support the medical necessity of this request to AmeriBen Medical Management:ATTN: Jenny Bunn Fax # 208-955-1502Phone: 208-955-1384Date Request Submitted: _______________________________________Patient Name: ________________________________________________ DOB: ________________________ Gender: M / F Address: _____________________________________________________________________________________________Patient ID Number: _____________________________________Patient Phone: ___________________________________Employee Name: _____________________________________ Employer Name: ___________________________________? See Attached Face Sheet for DemographicsType of transplant: ____________________________________________________________________________________Diagnosis Code/ICD 10(s):_______________________________________________________________________________Surgical Transplant CPT Code (will be used throughout transplant process, including evaluation): ______________________Requested Dates for Evaluation Period: ____________________________________________________________________?Outpatient ?Inpatient Facility Rendering Care: ________________________________________________________________________________Tax ID: _______________________________________ NPI: __________________________________________________Address: _____________________________________________________________________________________________Phone Number: __________________________________________ Fax Number: __________________________________Transplant Financial Coordinator or designated contact: ______________________ Phone Number: __________________?In Network Facility ? Out of Network Facility ? Center of Excellence ? Blue Distinction CenterProvider overseeing transplant (Specifically MD Name) _______________________________________________________ Tax ID: _______________________________________ NPI: __________________________________________________Address: _____________________________________________________________________________________________Phone Number: _________________________________________ Fax Number: ___________________________________Provider Contact Person: ______________________________ Phone Number: ____________________________________Please attach clinical documentation to support transplant necessity.Benefit Verification will be faxed upon completion. To verify eligibility, network status and any issues regarding claims, please contact the dedicated toll free # on the member’s ID card. ................
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