Please submit this form for Lucent Health Care UR Precerts only.
To initiate precertification for a patient, please fill out the form and attach medical documentation.
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SSN / ID Number
Insured SSN / ID Number
Relation to Insured
Date of Birth
Referring Physician / Provider Data
Provider / Facility Data
Contact Person / Dept. Info
Reason for Referral / ICD10 / CPT Code
Date of Service
Number of Visits
Attach Supporting Documentation