Telehealth Services PA Form - 4 Med Systems, Inc.

Form Template

This Telehealth Services PA Form covers these conditions:

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Recent hospitalization with a primary diagnosis of HF/COPD/CV conditions/diabetes. A history of failing to adhere to their treatment plan and are at risk for acute episode. Emergency department visits in the recent past for treatment of cardiac conditions including heart failure and hypertension, COPD and uncontrollable diabetes. The above conditions along with renal failure as defined as GFR<30, hepatic failure or coronary disease that puts the patient at risk for myocardial function compromise. Major system co-morbid conditions that complicates their chronic disease (i.e. heart failure, renal failure, diabetes, and respiratory illness). Requested service it for a home base primary care member a specialized (Priority Health Program).

Authorization confirmation will be available within 3 business days via Auth Inquiry in the online Provider Center at Once logged into the Provider Center, select Auth Inquiry from the tools on the right. Need a login for our provider center? Contact the provider helpline at 800. 942. 4765.

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