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Submit A Pre-Certification

Use this form to begin the pre-certification process for an MCM member.

Remember: Completion of this form does not guarantee
the member's claim will be approved.

NOTE: All fields are required except where identified as Optional.

All Clinicals/Support Documents for Pre-Approval
Must be Faxed to 850-765-0536

MEMBER INFORMATION
Member ID Number: MTL--
Member Name:
Patient Name:
DOCTOR INFORMATION
Hospital/Facility Name:
Hospital/Facility Phone:
Contact Name:
Best Time To Call:
Doctor's Name:
Name of Practice:
E-Mail:
Phone Number:
Address:
City:
State:
Zip Code:
PROCEDURE INFORMATION
CPT Code 1:
CPT Code 2: (Optional)
CPT Code 3: (Optional)
DX Code 1:
DX Code 2: (Optional)
DX Code 3: (Optional)
Procedure Status: Out-PatientIn-Patient
Date of Procedure:
Procedure Description:
Diagnosis Description:
Comments:
(Optional)
 
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MCM Maxcare is an affiliate of Medical Claims Management, Inc.

Medical Claims Management, Inc. • PO Box 13328 • Tallahassee, Florida 32317
850-727-5511 • Toll Free: 888-271-5838 • Fax: 850-765-0536

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