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INSTRUCTIONS FOR COMPLETING THE REM INTAKE/REFERRAL FORM PLEASE COMPLETE ALL REQUESTED INFORMATION Page 1 Referral Source: Referral source name, address, telephone number and fax number. Patient Information:
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What is rem intake application?
The rem intake application is a form used to request access to remittance information.
Who is required to file rem intake application?
Any individual or organization seeking access to remittance information is required to file the rem intake application.
How to fill out rem intake application?
The rem intake application can be filled out online or submitted in person at the designated office.
What is the purpose of rem intake application?
The purpose of the rem intake application is to provide access to remittance information for authorized individuals or organizations.
What information must be reported on rem intake application?
The rem intake application requires basic contact information, a reason for requesting access to remittance information, and any supporting documentation.
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