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SUBMIT TO:Hepatic Outpatient Treatment Request (OR) 125158 Research Blvd, Suite 400 Austin, Texas 78759 FAX 866.694.3649 Nonparticipating Providers DATE PROVIDER INFORMATION MEMBER INFORMATION PROVIDER
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How to fill out outpatient treatment request otr
How to fill out outpatient treatment request otr:
01
Start by gathering all necessary information such as personal details, contact information, and insurance information.
02
Identify the specific treatment or service you are requesting and provide a clear description of your needs.
03
Indicate the dates and times you prefer for your outpatient treatment.
04
Include any relevant medical history or previous treatment information that may assist the healthcare provider in understanding your condition better.
05
Ensure that the outpatient treatment request form is signed and dated.
06
Double-check all the information provided to ensure accuracy and completeness.
Who needs outpatient treatment request otr:
01
Individuals seeking outpatient medical or mental health services.
02
Patients who have been advised by their healthcare provider to undergo outpatient treatment.
03
Individuals who require ongoing medical or therapeutic care outside of a hospital or residential facility.
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