PROVIDENCE Prior Authorization Request Form
 ICD 10 Code(s)
  Requested Service(s)
 CPT Code(s)    
         # of Visits Requested
 Date of Procedure     **    
 Authorization Date Span
  Type of Service


  For Inpatient Services Only

    If PM admission is planned,       please provide justification:

 Contact Name      

 Contact Phone    

 Contact Fax          

 Total # of pages faxed, including cover page  
 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.