Fax Forms and Resources
In order for fax requests to be processed as quickly as possible, it is essential they are sent to the correct fax number. Each payer has a unique fax number listed below for your reference.
By Nicole1 author64 articles
Novitas - Medicare Fax Form & Education
High Tech Imaging Authorization Request Form (BlueCross BlueShield of Tennessee Only)
Referral Request Form (For All Payers)
Fax Form for All Clients
Fax form: Diagnostic imaging
Part 1 Fax Form (Diagnostic imaging)
Part I Fax Form (Cardiovascular)
Part I Fax Form (Musculoskeletal, therapy services)
Fax Form: Epidural Steroid Injections, Outpatient
Fax Form: Coronary Computerized Tomography Angiography (CCTA)
Fax Form: Facet Injection / Medial Branch Block (MBB)
Fax Form: Catheter-based Angiogram & Revascularization
Fax Form: Foot Surgeries, Bunionectomy and Hammertoe
Fax Form: Carotid Endarterectomy & Carotid Artery Stenting
Fax Form: Hip Arthroplasty
Fax Form: Hip Arthroscopy
Fax Form: Cardiac Computerized Tomography Angiography
Fax Form: Knee Arthroplasty
Fax Form: Cardiac Rehabilitation
Fax Form: Knee Arthroscopy
Fax Form: Right Cardiac Catheterization and/ or Left Ventriculogram
Fax Form: Neuromuscular Stimulators, Spinal Cord Injury
Fax Form: Cardiac Positron Emission Tomography (PET)
Fax Form: Neuromuscular Stimulators, Other Injury
Fax Form: Cardiac Implanted Device (Pacemaker)
Fax Form: Occupational Therapy, Outpatient
Fax Form: Cardiac Implanted Device (Defibrillator)
Fax Form: Pain Infusion Pump
Fax Form: Cardiac Ablation
Fax Form: Physical Therapy (Outpatient)
Fax Form: Cardiac Catheterization, Other
Fax Form: Radiofrequency Ablation (RFA)
Fax Form: Left Cardiac Catheterization
Fax Form: Sacroiliac (SI) Joint Injections
Fax Form: Ventricular Assist Device (VAD)
Fax Form: Shoulder Arthroplasty
Fax Form: Transthoracic Echocardiogram (TTE)
Fax Form: Shoulder Arthroscopy
Fax Form: Transesophageal Echocardiogram (TEE)
Fax Form: Speech Therapy (Outpatient)
Fax Form: Transcatheter Aortic Valve Replacement (TAVR)
Fax Form: Spinal Cord Stimulator
Fax Form: Tc-pyrophosphate Scan
Fax Form: Spinal Fusion and Decompression
Fax Form: Surgical Left Atrial Appendage Occlusion
Fax Form: Vertebroplasty and Kyphoplasty
Fax Form: Stress Echocardiogram
Fax Form: Percutaneous Coronary Intervention (PCI), Coronary Angioplasty Stent
Fax Form: Myocardial Resection
Fax Form: Myocardial Perfusion Imaging (MPI-SPECT)
Fax Form: Magnetic Resonance Imaging (MRI)
Fax Form: Ligation & Stripping
Fax Form: Internal Loop Recorder
Fax Form: Inpatient Rehabilitation & Skilled Nursing Facility
Fax Form: Home Health, Speech Therapy, Physical Therapy, Occupational Therapy
Fax Form: Fractional Flow Reserve (FFR)
Fax Form: External Wearable Device
Fax Form: Endovascular/ Hybrid Repair, Open Surgical Repair, and Endovascular Repair/ Open Surgical Repair Hybrid
Fax Form: Electrical Cardioversion, Elective
Fax Form: Duplex US, CT of Head
Fax Form: Computerized Tomography Angiography (CTA)