DMEPOS Fax Confirmation

*External Use Only *


For multiple sites please submit a separate request for each location.*


**Please do not submit a fax confirmation if you have submitted a "Provider Information Form".**


Carelon is committed to protecting member's Protected Health Information (PHI). To prevent disclosure of PHI to unauthorized recipients, Carelon requires confirmation of your phone and fax number. Carelon must receive this completed form prior to faxing authorization notifications.



 

*Name of person completing confirmation form*

 

*Please type out email address in full*

 

*In case clarification is needed*

Phone
 
 

Provider Information

 
 
 
 
 
 
 
 
 

Provider Contact Information

 
 
 

*Secure fax numbers as member/patient information may be sent via fax.*