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Placement Information

All fields marked with an asterisk (*) are required.

Placement Type

Acceptance Window (min) *

Service Start Date *

Service Coordinator

Profile Information

Phone Number

123-456-7890

Address

123 Fake St.

ZIP Code

12345

Payer D/C Date

N/A

Insurance

Insurance Name

Aetna Better Health

Insurance Number

123456

Start Date

01/01/2020

End Date

01/01/2021

Special Request

Male / Female

Primary Language

Secondary Language

Other

Authorization

All fields marked with an asterisk (*) are required.

Send Placement without Authorization

Use Existing Authorization

Authorization Number *

Authorization Type

From Date *

To Date *

Service Category *

Service Type *

Provider *

Confirmed

Service Code *

Service Code Type

-

Diagnosis Code 1 *

Add Placement for Thomas Jefferson Active

Placement Information

Profile Information

Insurance

Special Request

Authorization