Liberty Slots Authorization Form
Completion of the form is mandatory, failure to provide required information may result in delay in response to or disapproval of your request. Ship or station: 4. Date of request: (yyyymmdd) 5. Department/division: 6. Duty section/group: 7. Nature of request: leave special liberty. Special pay commuted rations. PREAUTHORIZATION AND CONCURRENT REVIEW REQUIREMENTS For certain services, your doctor must obtain prior approval. Below is a list of those services. LIBERTY Dental Plan Specialty Care Referral Request P.O. Box 26110 Santa Ana, CA Phone: 888-703-6999 Fax: 949-253-0096 Referral #.
Terms and ConditionsREQUEST FOR AUTHORIZATION OF SERVICES FORM Call UM at 844-854-6884 opt 3 (Call Center Hours M-F 8a – 5p) FAX Form and Clinical to 800-886-0669. PLEASE DO NOT SEND REQUESTS FOR MULTIPLE MEMBERS TOGETHER IN ONE FAX – MUST SEND SEPARATELY Member Name Date of Birth Member’s Plan ID Is Referring Provider: Plan NP. Name of Nursing Facility. Browse important resources that are available to download from Liberty HealthShare. Prenotification Request Form (PDF) PDF 183 kb.
so you know that we have thought of everything. The protection of your data and funds is our most important procedure and making sure that you can make a deposit/withdrawal at your convenience and with as little effort as possible.