Avergent Provider Inquiry

Care Advocate Name

Care Advocate Email

Call Type

If, Provider Call

If, calling for Pre-Auth, facility type:

If, Pre-Auth, facility name:

Employer Name (PLAN):

Plan Type:

Patient Name

Patient DOB

Patient Email

Preferred Method of Communication

Patient Phone

Patient Home City

Provider Type Requested

If a Specialist, type of: (i.e, Cardiology)

Distance Willing to Travel

Referring Provider Name

Referring Provider Phone #

Appointment Scheduled (Y or N)

If YES, Date of Appt:

Benefits Quoted for Service(s) Inquiry

Yes

Pre-Authorization Disclaimer Provided to Member

Yes

Referred TO Location Address:

Name of service(s) being requested. Include CPT Code(s) if available.

Prior medical treatment received such as (imaging, labs, PT, ) related to this request.

Additional Pertinent Comments:

1400 Lombardi Ave | Suite 201 | Green Bay, WI 54304

help@avergent.com

866-247-5415