Standard Prior Authorization Request Form

Section I — Please fax your request to 866-756-9733.
Date and Time Submitted:    
   
/
/ / /
Section II — General Information
Review Type:        
Clinical reason for urgency
Request Type:    
/ /
(Prev. Auth#: )
Section III — Patient Information
Name
Patient Preferred Phone #
DOB

Sex:  
Subscriber Name (if different)
Member ID #
Group #
Section IV — Provider Information
Requesting Provider or Facility Name
Service Provider or Facility Name
NPI # or Tax ID #
Specialty
NPI # or Tax ID #
Specialty
Phone #
Fax #
Phone #
Fax #
Address
Address
Name of Primary Care Provider
Phone #
Fax #
Section V — Services Requested (with CPT, CDT, or HCPCS Code) and Supporting Diagnoses (with ICD-10 Code)
Planned Service or Procedure
Code(s)
State Date
End Date
Diagnosis Description
Code(s)
   
Number of Sessions
Duration
Frequency
Other
    MD signed order must be attached to this request. Please also attach the nursing assessment.
Number of Visits Requested
Duration
Frequency
Other
    MD signed order must be attached to this request.
Equipment / Supplies (Include any HCPCS Codes
Duration
Section VI — Clinical Documentation
Please provide a brief explanation of medical necessity for service(s) and attach supporting clinical documentation with this request.
Please provide contact information, in case we need more information
Name
Phone
(ext.
)
Email
Preferred meathod of contact is:
Section VII — Reason for Denial or Partial Denial