Modern Fax Cover Sheet Sample

Fax Cover Sheet
Utilization Management
Fax (919) 560-7377
Date:      
To:
Utilization Management
From:
Name:      
Agency:      
Phone:      
Consumer Name (First Name, Last Name):      
MR#:      
DOB:      
Type of Document in Fax or Request:
Initial Intake
LME Consumer Admission & Discharge Form
Target Populations Form
Intro PCP
New Service Authorization (ITR + PCP or Service Plan & Service Order)
Additional (New) Services (ITR + revised PCP or Service Plan & Service Order)
Reauthorization ITR
ORF2 + Service Order
Additional amount of current service
PCP (New or Revised)
Facility Based Crisis
Treatment Summary
Discharge Summary (LME Consumer Admission & Discharge Form)
Transfer Summary
Data Update (address, diagnosis, target population, funding, etc.)
LME Consumer Admission & Discharge Form
Target Populations Form
Hospital Authorization/Referral
Other (circle or explain) ACTT, DCA
Additional Information:      
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Modern Fax Cover Sheet Sample DOC

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