Service Request Form printable pdf download

Tracking#:________________________

Please include Tracking number on claim.

Expiration Date: _____________

Medi-Cal & HF Prior Authorizations:

Medicare Prior Authorization:

Phone: 800-526-8196 ext. 126400

Phone: 800-526-8196 ext. 129105

Fax: 800-811-4804

Fax: 866-472-0596

SERVICE REQUEST FORM

-CAL

HEALTHY FAMILIES

MEDICARE

RODUCT

EDI

Service is:

NON-URGENT

URGENT

ABUSE OF URGENT PA STATUS WILL

BE MONITORED. Urgent request MUST be reserved for requests that are potentially life threatening or pose a

significant risk to the continuous care of the patient, in the provider’s best professional judgment. MHC reserves

Date:

judgment of urgency and must meet definition above, therefore, please explain reason for urgency below.

Member Name (Last, First, Middle Initial)

Date of Birth

Mem I.D.(Social Security Number)

Address (No., Street, City, State, Zip)

Phone Number:

(

)

Referral/Service Type Requested

Specialist Consult/Tx/FU Care

Requested LOS:_________________

Surgical Procedure

Inpatient Admission

Facility: ________________________

Inpatient

Major Diagnostic Procedure

Outpatient

Date/Time of Service: _____________

Home Health

Hospice

Other: ______________________

DME (refer to PA list)

Comments:___________________________________________________

Requesting Provider Information

Referring To Provider Information

Requesting provider name (last, first)

Referring to provider name (physician, mg/ipa, facility, agency)

Address: (No,, Street, City, State, Zip)

Specialty

Phone Number (

)

Phone Number (

)

Fax number (

)

Fax number (

)

Service Request Information

ICD-9 Code #/Description:

Code or Description:

Clinical indications for request:

(include pertinent past medical hx. treatment, physical findings, and attach all relevant medical records and test results, etc)

Requesting Practitioner Signature:

Date:

MOLINA Use Only

Criteria/guidelines met:

yes

Authorization Status:

approved

modified

deferred

denied

Comments:

UM representative signature:

Date:

Approved LOS:

MEDICAL DIRECTOR REVIEW

APPROVED

COMMENTS:

MODIFIED

DENIED

MEDICAL DIRECTOR SIGNATURE: ______________________________

Date: _____/_____/_____

Confidentiality Notice: This fax transmission, including any attachments, contains confidential information that maybe privileged. The information is intended only for

the use of the individual(s) or entity to which it is addressed. If you are not the intended recipient, any disclosure, distribution or the taking of any action in reliance

upon the fax transmission is prohibited and may be unlawful. If you have received this fax in error, please notify the sender immediately via telephone at the above

phone number and destroy the original documents. Thank you.

CLAIMS PAYMENT IS CONTINGENT ON MEMBER ELIGIBILITY FOR DATE(S) OF SERVICE

MOLINA

FORM: 1451

10/17/2012