Soteria Healthcare v2024 | Date Extension Request Form

Date Extension Request Form v2024
Date Extension Request Form
CHIROPRACTIC OFFICE INSTRUCTIONS:

Soteria Healthcare Network Date Extension Form (v2024)
Please complete and return to Soteria Healthcare Network or print and fax back to Soteria @ 404-341-9804. As always, if you have any questions/comments, please call 770-455-8190 ext 135.

IMPORTANT: Date Extensions may only be requested up to 2 weeks after the authorization has expired.
Name of Patient*

Patient First NamePatient Last Name
Patient Member # er*
Authorization # er*
Date Parameters of Authorization
Effective Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date
Visits Authorized*
Visits Used*
Reason for Date Extension Request/Comments*
Treating Doctor (Printed Full Name)*
Today's Date*

MonthDayYear
Date
Treating Doctor (Signature)*

Clear
Quesions, Please call Soteria Healthcare at tel. 770-455-8190 (M-F) 9am-5pm ET.
Should be Empty:

Date Extension Request Form