Common Contracts

Single Case Agreement (SCA) Request Form

Single Case Agreement (Sca) • May 18th, 2022

• Contract Type
  Single Case Agreement (Sca)
• Filed
  May 18th, 2022

Medicaid Participant Information Last Name: First Name: Initial: Medicaid ID: DOB: Phone: Primary Insurance Provider: Primary Subscriber ID: Secondary Insurance Provider: Secondary Subscriber ID: Treating Facility/Physician Information Facility Name: NPI: Physician Name: NPI: Coordinating Contact Person: Email: Phone: Fax: Billing Contact Person: Email: Phone: Fax: Referring Physician Information Physician Name: NPI: Contact Person: Email: Phone: Fax: Physician Signature: Date: Requested Service(s) CPT Codes &Modifier, ifapplicable Description Quantity Estimated Admission Date Estimated Discharge Date Required Documentation ☐ Letter of medical necessity from referring provider, indicating why, for example, care at a non-enrolled tertiary care facility is necessary☐ Clinical notes, within the last six (6) months, to support the single case agree