• Step 1Facility & Patient Information
  • Step 2Clinical Information
  • Step 3Complete Form

Facility & Patient Information

Instructions:

Fields marked with an asterisk are required. The certification is not valid until you receive a certification number from us. All requests are subject to review. We may require additional documentation for some services. Please print your request at the end of the submission process for your records.

Facility Information
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The Facility's Tax I.D. is a 9 digit number.

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An NPI, or National Provider Identifier is a unique 10-digit identification number issue to health care providers in the U.S. by the Centers for Medicare and Medicaid Services(CMS).

Facility's Physical Address
Reporter Information
Patient Information