Utilization Review, PREAUTHORIZATION & PRECERTIFICATION

The Hines & Associates, Inc. online precertification tool provides a simple and efficient way to submit a precertification request. Before beginning the online submission process, it is best to gather the information required to complete the entire form. The form must be completed and submitted in a single session. For security purposes, this tool limits your internet browser’s idle time 20 minutes. If, at any time, you wish to discontinue the submission process, please be sure to close your internet browser to ensure that any data entered is no longer viewable on your computer. All information is erased on your computer, as well as on any Hines servers whenever your internet browser is closed.

Follow these instructions:

• Complete the fields below with its required information.
• In the Comments field, list the physician and facility names (with their respective city and state) along with NPI number (if available), and any additional pertinent information not included in the records being attached.
• Attach clinical records with patient chart demographics or copy of insurance card included to this form by clicking on the Upload File button and locating the document you wish to attach.
• Click on the Submit button. You will receive instant web-based notification of your submission’s success or failure.

Contact Information

last name

first name

phone

insured Information

last name

first name

insured id #

patient Information

last name

first name

date of birth

Medical information

Admission Date

Comments
In this Comments field, list the physician and facility names (with their respective city and state) along with NPI number (if available) and any additional pertinent information not included in the records being attached. A response to your request will be provided via secure email upon completion of the review. Please enter an email address we can use for this purpose.

ATTACHMENT