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MTC Podiatry Services Treatment Request Form Required for: Managed Long Term CARFAX: (716) 8038727 Fidel is Care Member Name (Last, First, M.I.):Questions: (888) 3433547Member Information Fidel is
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How to fill out 2019-fidelis-care-mltc-podiatry-services-request-form-english 2019-fidelis-care-mltc-podiatry-services-request-form-english

01
Download the 2019 Fidelis Care MLTC Podiatry Services Request Form - English from the official website.
02
Print out the form and fill in the required details, such as your personal information, insurance details, and specific podiatry service requested.
03
Make sure to provide accurate and complete information to avoid any delays or errors in processing your request.
04
Attach any supporting documents or medical reports that may be required for the requested podiatry service.
05
Review the form and double-check for any errors or missing information before submitting.
06
Submit the completed form either by mail or fax, as instructed in the form's guidelines.
07
Keep a copy of the filled-out form for your records.
08
Wait for a response from Fidelis Care regarding the status of your request. If approved, you will receive further instructions on scheduling the podiatry service.

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01
Individuals who are Fidelis Care members and require podiatry services can use the 2019 Fidelis Care MLTC Podiatry Services Request Form - English.
02
This form is specifically for members enrolled in the Managed Long-Term Care (MLTC) plan offered by Fidelis Care.
03
It is intended for those who need podiatry services and want to request coverage or authorization for specific treatments or procedures.
04
The form helps Fidelis Care assess the necessity of the requested podiatry services and determine if coverage should be provided.
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It is a form used to request podiatry services under Fidelis Care MLTC.
Members of Fidelis Care MLTC who need podiatry services.
The form must be completed with the member's information, doctor's recommendation, and specific details of the requested podiatry services.
The purpose is to request and authorize podiatry services for Fidelis Care MLTC members.
The form requires information such as member's details, physician's recommendation, type of service requested, and any relevant medical history.
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