PO Box 40384
Portland, OR 97240


Commercial Authorization / Referral Request Form
(503) 243-4496   (800) 258-2037   Fax (503) 243-5105
If you require a RUSH Prior Authoriaztion for a procedure being done within 48hrs, please
call Moda Health at (503) 243-4496 or (800) 258-2037

Patient Information
Patient Name
DOB
ID #
Subscriber Name
Group #
Group Name
PCP / On-Call Doctor Information
PCP / On Call Doctor
TIN #
Phone #
Ext #
Fax #
Contact
Specialist Information
Specialist Name
TIN #
Phone #
Ext #
Fax #
Contact
Address / Location
Facility Information
Facility
TIN #
Phone #
Ext #
Fax #
Contact
Address / Location
Authorization / Referral Information
ICD Code(s)
   
CPT/HCPCS Code(s)
   
Service Description
to
Scheduled Date
For Medications Administered in Provider Office Only
Requested Dose and Treatment Interval
Additional Comments
Updated 04/13/2017