Providence Authorization

PROVIDENCE Prior Authorization Request Form

Requesting Provider

Primary Care / Personal Physician

Patient Name

Member / Patient ID Number

Patient Address, City, State, Zip

DOB

Group #

ICD 10 Code(s)

Requested Service(s)

CPT Code(s)

Consult Diagnostics

Office Visit # of Visits Requested

Date of Procedure ** TBD

Other

Facility

Authorization Date Span

Facility TIN#

Facility NPI#

Referred to Provider:
Provider TIN# Provider TIN#

Referred to Provider's Phone #

Referred to Provider's Address, City, State, Zip

Comments

Type of Service

Inpatient

Outpatient Surgery

Office Surgery

Outpatient Diagnostics

ASC

For Inpatient Services Only

If PM admission is planned, please provide justification:

****REQUIRED****

Contact Name

Contact Phone

Contact Fax

Total # of pages faxed, including cover page

Please EXPEDITE !! The provider believes 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 (CMS definition)

This form must be filled out completely. Chart notes are required and need to be submitted with this request. Incomplete requests will be returned to the requestor.

Please Review for IN NETWORK BENEFITS.