This form may be returned unprocessed if not completely filled out with all requested information. Authorizations will
be given for medically necessary services only. This request cannot be processed without supporting documentation.
(Completed within
14 days of receipt.)
(Choose ONLY if you are attesting that waiting
for
a decision under the standard time frame could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy. Completed within 72 hours of receipt.)
Section > 1 Patient Information
Section > 2 Requesting provider (PPO plans) primary care provider (HMO plans) information
Section > 3 Servicing provider or specialist information
Section > 4 Facility Information
Section > 5 Service Requested
to
CPT-4/HCPCS code
Description of procedure or services
Visits/frequency
Ready to submit? Fax to 855-637-2666 or mail to
Moda Health, Attn: Medicare Authorization Department, PO Box 40384, Portland, OR 97240
