Precertification Request Form

Precertification Request Form
Please complete the precertification request below with as much information as possible. You will receive a response within 48 hours of the first business day following the request.

Send Medical Records and/or Clinical Notes via fax at (833) 330-2739 or email to precert@veracity-benefits.com or via file upload at the bottom of the form.

For questions regarding this request or if you don’t receive a response within 48 business hours, please contact Veracity Care Solutions at 888-324-1747 during regular business hours from Monday-Friday, 8 am-5 pm ET.

Disclaimer: Authorization is based on medical necessity only and does not guarantee coverage, benefits, and/or eligibility. Contact the plan administrator for benefits and eligibility information.

Submitter Information
Name
Phone
Please enter a valid phone number.
Fax
Please enter a valid phone number.

Patient Information
Member ID
Name

First NameLast Name
Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
Gender
Address

Address

Street Address Line 2

CityState

Zip
Phone
Please enter a valid phone number.
E-Mail
example@example.com

Insurance Information
Insurance Company Name
Group Name / ID
Member PPO Network
Is this Primary Insurance?
If no, who is Primary Insurance Carrier?
IMPORTANT: ICDs/CPTs must be added one at a time. Please click Add More to add an entry for Diagnoses and/or Procedures.
Diagnosis
Procedure
Admit Date or Start Date

MonthDayYear
Date
Discharge Date or End Date

MonthDayYear
Date
Number of Requested Days/Sessions/Units

Insured Information
Relationship to Patient

Physician Information
EIN / Tax ID
NPI
Name

First NameLast Name
Specialty
Type
Is Physician in Network?
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Zip
Phone Number
Please enter a valid phone number.
Fax
Please enter a valid phone number.

Facility Information
EIN / Tax ID
NPI
Name of Facility
Is Facility in Network?
Address

Address

Street Address Line 2

CityState

Zip
Phone Number
Please enter a valid phone number.
Additional Information (if needed)
File/Document(s) Upload

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Disclaimer: Authorization is based on medical necessity only and does not guarantee coverage, benefits, and/or eligibility. Contact the plan administrator for benefits and eligibility information.

For questions regarding this request or if you don’t receive a response within 48 business hours, please contact Veracity Care Solutions at 888-324-1747 during regular business hours from Monday-Friday, 8 am-5 pm ET.
Please verify that you are human*
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