Preadmission Certification Program: Physician Information and Consent Form

To the Doctor This patient is covered by [Insurance Company Name] Preadmission Certification/Continued Stay Review Program. This program requires that all decisions to hospitalize the patient be reviewed by [Medical Review Services Company Name] personnel. Based on your patient's clinical status and the treatment plan you have outlined, [Medical Review Services Company Name] will notify you regarding the outcome of the certification review. A Medical Review Specialist will contact you at periodic intervals during the hospitalization to discuss your patient's progress, further treatment plans, and need for continued inpatient care. In some cases, the patient may also need to obtain a second surgical opinion for certain elective procedures.

The patient will fill out this physician Information/Consent Form and present it to you. You or your patient must contact [Medical Review Services Company Name] to provide the information noted on this card.

Failure to participate can result in your patient having to pay significantly increased out-of- pocket expenses for treatment.

To the Employee If your doctor is recommending hospitalization for you or one of your covered dependents, first have the patient (parent or guardian if patient is a minor) sign the authorization on the back of this form, and fill out the blanks below. Then give this form to your doctor. You or your doctor must contact [Medical Review Services Company Name] prior to hospitalization.

It is your responsibility to see that [Medical Review Services Company Name] is notified.

Patient Name: ______

Date of Birth: ______Age: ______Social Security #: ______

Address: ______

Phone #: ______Sex:  M  F

Occupation: ______

Employer Name: ______

Employer Address & Phone #: ______

Insurance Carrier: ______

Insurance Policy or Certificate #: ______

1 Here's what the doctor needs to tell [Medical Review Services Company Name]:  Insured's name  Patient's name  Patient's symptoms and their duration  Results of physical examination, lab tests, and x-rays  Admitting diagnosis  Medical and surgical treatment plan  Name and location of the hospital where the patient is to be admitted  Number of days of hospitalization you feel will be needed, proposed admission date, and date of any scheduled surgery

You or your doctor must call [Medical Review Services Company Name] at their office seven working days before the scheduled admission and provide them with this information.

In the event of an emergency hospitalization or a delivery, call [Medical Review Services Company Name] within twenty-four hours or on the first working day following a weekend or holiday.

Consent to Release Information I hereby authorize [Medical Review Services Company Name]'s representatives to view and obtain copies of all medical and related records of the above-named patient, pertaining to the medical treatment/hospitalization described on this form. This information is solely for the use of [Medical Review Services Company Name] and the insurance carrier or claim administrator in assessing medical services and documentation and will not be shared with any other person or organization without my written consent unless expressly permitted by law.

I understand that this authorization may be revoked by written notice from me to [Medical Review Services Company Name]. Any revocation will not apply to information already released. If not revoked, this authorization will be valid while the claim is pending or a maximum of one year from the date it is signed.

______Signature of Patient or Guardian Date