Centralized Appointment Scheduling
Claims Administration
Credentialing
Reporting
Phone: 1-800-767-6747
Fax: 1-800-479-1070
E-Mail :
scheduling@Porteck Health Networks.com
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Case Manager Name:
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Company:
Case Manager Email:
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Case Manager Phone:
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Case Manager Fax:
Case Number:
Patient name: last, first
Patient Address:
Patient City:
Patient State:
Patient Zip:
Patient Phone:
Patient Cell phone:
(if available)
DOB:
SS#:
Date of injury:
Name of employer:
Carrier name:
Carrier bill to address:
Referring physician name:
Referring physician phone:
Referring physician fax:
Diagnosis names:
Diagnosis codes:
Requested test name:
CPT code:
Additional test name #:
CPT code:
Additional test name #2:
CPT code:
Additional test name #3:
CPT code:
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