Inpatient Hospital Admission Notification Form

Reason for Request and Type (page 1 of 3)
Inpatient hospital admission type, please check any of the following reason(s) that apply:

Name of Person submitting this notification: 
Phone (with area code): Fax (with area code):
To receive a case reference number & LOS please supply an e-mail address:

Check the status of any past requests here.

Please follow-up with PreferredOne IHS Department (800.997.1750 Option #2) for status of this request.