Case Management Referral Form

Case Management Referral Form

Complete the following form and submit the appropriate clinical information (clinical information can be submitted to casemanagement@fchn.com or faxed to (888) 272-3289). For questions call Medical Management department  (800) 808-0450.

Warning

You are using a test environment. Any submitted requests are not valid.

Please visit www.fchn.com to submit a valid request to Medical Management.

Contact Information
Patient Information
Subscriber Information
Facility Information
Reason For Referral
Medical Information
Diagnosis Codes
Procedure Codes
  

Warning

You are using a test environment. Any submitted requests are not valid.

Please visit www.fchn.com to submit a valid request to Medical Management.