Olympus Pre-certifications

Provider Portal

First Name:*

Last Name:*

Phone *

E-Mail:*

Patient First Name*

Patient Last Name*

Patient Date of Birth*

POLICY OR ID #*

Insurance Company*

Date of Service*

TBD

DIAGNOSIS / CHIEF COMPLAINT*

SERVICES BEING REQUESTED*

Include CPT codes if known

SERVICE TYPE*

Inpatient
Outpatient

State

City

NPI NUMBER

TAX ID

First Name:

Last Name:

Phone

Fax Number:

NPI NUMBER

NAME

Phone

Fax Number:

TAX ID

MEMBER ADMITTED TO A FACILITY

Case Mgmt. / UR Dept. Phone #

Case Mgmt. / UR Dept. Fax #

ROOM #

Medical Record #

COMMENTS:

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