Additional Networks Homepage » VAD/Cardiac » Submit a VAD Maintenance Referral

Submit a VAD Maintenance Referral

VAD/Cardiac

Please use this form to submit a referral to INTERLINK Health Services Inc. for an AdditionalNETWORKS Service. Fill out the form completely and click "Submit" to immediately send your referral to INTERLINK.

NOTE:  INTERLINK will provide the financial terms of an in-network facility to you within 48 hours of referral receipt.  To help us continue to process your referral in a timely manner, please provide all requested information.

Contact Information
Name:
Company:
Street Address:
City, State, Zip:
Email:
Phone:
Fax:
Patient Information
Patient Name:
Patient Residence Street Address:
City, State, Zip:
Employer Group Name:
Employer Group City, State:
Insured ID:
Date of Birth:
Sex:
Diagnosis:
Procedure Information
Contract Selection:
VAD Placement Date:
Is Patient Currently Inpatient:
If No, Date of Discharge:
Facility Information
Name:
City, State:
Case Management Information
Case Manager:
Company:
City, State:
Phone:
Email:
Reinsurer or MGU Information
Reinsurer:
Company:
City, State:
Contact:
Phone:
Email:
Claims Payment Information
Contact:
Company:
Street Address:
City, State, Zip:
Phone:
Fax:
Email:
Benefit Coverage Information
Health Plan Coverage:
Medicare Advantage Plan:
Group Renewal Date:
Type of Plan:
Additional Comments: