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Please call (317) 655-4500 for Emergency Medical Evacuation
requests. Do not use this form for Evacuation requests. You will be notified upon
receipt of this precertification. Precertification is not a guarantee of payment
nor is it a denial. It remains the insured person's responsibility to verify benefits.
All conditions and provisions of the insured person's certificate of insurance apply.
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If you are an IMG certificate holder, please visit MyIMG
to initiate your Precertification.
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Is this Precertification Initiation Form being submitted by the Provider?
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* Denotes a required field |
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Patient Information |
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Name of Insured* |
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Certificate / Group Number* |
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Date of Birth*
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Country*
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Address* |
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Address 2 |
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City* |
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State or Province
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(US & Canada only)
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Postal Code |
(US
& Canada only)
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Region
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Phone Number* |
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Fax Number |
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E-mail Address* |
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How would you prefer to receive the Precertification letter?
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If additional information is needed to complete the Precertification,
is it okay to contact you by e-mail?
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Would you like a Verification of Benefits to be forwarded to you
within two business days via e-mail?
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