For Administrative Services Only (ASO)
Members: Fax to: 1 (844) 679-7763 for medical
services / supplies and 1-888-496-1540 for
behaviorial health or
Mail to: PO Box 2998, Tacoma, WA 98401-2998
For Commercial and Individual Members:
Fax to: 1 (855) 232-0090 for medical services / supplies
and 1-888-496-1540 for behavioral health or
Mail to: PO Box 1271, WW5-53,
Portland, OR 97207-1271

Used for skilled nursing, long term acute care, inpatient rehabilitation, behavioral health services, inpatient and outpatient surgeries, outpatient medical services, transplants, DME and professional services.

Instructions: This form should be filled out by the provider requesting the service or DME. Please complete all applicable fields. Prior to completing this form, please confirm the patient's benefits, eligibility and if pre-authorization is required for the service.
Have you verified if pre-authorization is required?
*Note: if no, please verify with the preauthoriaztion list on the Provider Web site or call the number on the back of the member's card. Is this request:
If you already have an authorization number, please list it here:
SECTION 1 - PATIENT INFORMATION
Patient Name (Last)
First
MI
Patient's Phone Number
Patient's Regence Member Number
Group Number
Date of Birth (mm/dd/yyyy)
SECTION 2 - PROVIDER INFORMATION
Please Check One:
Provider Name
Tax ID Number
NPI
Phone Number
Confidential Voice Mail
Fax Number
Provider Address
City
State
Zip Code
Who should we contact if we require additional information?
Name
Phone Number (include ext)
Confidential Voice Mail
Fax Number




SECTION 3 - PREAUTHORIZATION REQUEST
Is this request:
or
Date of Service (if scheduled)    
    (mm/dd/yyyy)
Please Check One:
Please check all that apply:
Rendering or Treating Provider and Provider Specialty
Physical Address where services will occur
City
State
Zip Code
IF INPATIENT OR OUTPATIENT FACILITY
IF DME
Facility Name
Company Name
Anticipated Admission (mm/dd/yyyy)
Anticipated Length of Stay
Tax ID Number:
NPI:
Note: If anticipated length of stay is not indicated, no more than two days will be assigned if approved.

Note: This form does not serve as a notification of admission. Please reference the Provider Web site for instructions to notify us of an admission.
DME Address:
City:
State
Zip Code
Signed copy of prescription attached:
Invoice attached:
If this is an expedited request and meets the definition indicated below, please check the expedited request box AND fax this form to 1 (855) 240-6498 or ASO Fax to 1 (844) 679-7764.

Expedited is defined as: when the Member or his / her physician believes that waiting for a decision under the standard time frame could place the Member's life, health, or ability to regain maximum function in serious jeopardy.
Please provide all diagnosis, CPT® or HCPCS codes and their descriptions, if available; this will help processing of your request.
Diagnosis code(s) and description(s):
CPT® or HCPCS code(s) and description(s):
DME Only Line Item Cost
Primary:  
$
Second:  
$
Third:      
$
Please submit the following clinical documentation with this form as appropriate for this request:
  History & Physical     Lab/Radiology/Testing Results     Current Symptoms & Functional Impairments
Treatment History and any other information such as chart notes that support medical necessity for the request.