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Intensive Behavioral Health Services (IHS) FeeforService (FFS) to Performer Transition Form ** Note: This form should only be used when submitting IHS transition requests for Members whose Medicaid
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How to fill out ibhs-fee-for-service-transition-authorization-request-formpdf
How to fill out ibhs-fee-for-service-transition-authorization-request-formpdf
01
Fill out the patient's demographic information including name, date of birth, address, and contact information.
02
Provide the patient's insurance information including policy number, group number, and insurance company name.
03
Indicate the reason for the authorization request and provide any supporting documentation if necessary.
04
Fill out the requested dates of service and the healthcare provider's information.
05
Review the form for completeness and accuracy before submitting it to the appropriate party.
Who needs ibhs-fee-for-service-transition-authorization-request-formpdf?
01
Healthcare providers who are requesting fee-for-service transition authorization for their patients.
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What is ibhs-fee-for-service-transition-authorization-request-formpdf?
ibhs-fee-for-service-transition-authorization-request-formpdf is a form used to request authorization for transition of fee-for-service services.
Who is required to file ibhs-fee-for-service-transition-authorization-request-formpdf?
Providers who offer fee-for-service services are required to file ibhs-fee-for-service-transition-authorization-request-formpdf.
How to fill out ibhs-fee-for-service-transition-authorization-request-formpdf?
To fill out the form, providers must input all required information accurately and submit it by the deadline.
What is the purpose of ibhs-fee-for-service-transition-authorization-request-formpdf?
The purpose of the form is to request authorization for transition of fee-for-service services.
What information must be reported on ibhs-fee-for-service-transition-authorization-request-formpdf?
Providers must report details of the fee-for-service services being transitioned and any relevant patient information.
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