Atrio Authorization Form

Prior Authorization Request Form
Medical Service and DME Supplies

Instructions: * Indicates required information – Form may be returned if required information is not provided. Please fax this request to the appropriate fax number listed at the bottom of the page.

Standard Review: 14 days. (Attach supporting documentation).

Please include a date if you are requesting the authorization be completed more quickly than the 14-day timeframe for scheduling accommodations: . We will try our best to process this requests by the date requested.

Expedited Review: 72 hours. If standard timeframe could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. (Attach supporting documentation).
An expedited review is not intended for scheduling accommodations. A request may be downgraded if it does not meet life or limb criteria.

Please Note: Retroactive requests need to be sumbitted as a claim.

Requestor Information

*Date:

Person Completing Form:

Phone:

*Provider / Clinic Name:

Fax:

Member Information

*Name:

*ID #:

*Birth Date:

Requesting Provider Information

*Name:

*Phone:

Fax:

Address:

Appointment is scheduled for:

Delivering Provider / Facility Information

Name :

ICD-10 Code(s):

Address :

Phone:

Procedure / Service / Item Information

CPT/HCPC & Modifier	Description	Quantity	Start Date	End Date

Surgery
Information

Outpatient Hostpial or ASC
Date:

Inpatient: YES NO
Admit Date: Discharge Date:

Fax completed forms with supporting documentation to the appropriate county fax number below:

Douglas: 541-672-4318

Klamath: 541-882-6914

Jackson & Josephine: 866-500-8773

Marion & Polk: SNF & Hospital (503) 485-3320, other Prior Authorizations (503) 581-7422

THIS AUTHORIZATION IS NOT A GUARANTEE OF PAYMENT. PAYMENT IS BASED ON BENEFITS IN EFFECT AT THE TIME OF SERVICE, MEMBER ELIGIBILITY AND MEDICAL NECESSITY.