Medical Prior Authorization Request Form

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Medical Prior Authorization Request Form
Do not use this form for pharmacy prior authorization requests.
Please visit to find the appropriate pharmacy form.
Today’s date
/
/
Fax to: 888-415-9055
Urgent
Routine
Member information
Please verify the member’s eligibility before rendering services.
/
/
Member name
Member ID #
DOB
Member address
Member phone
-
-
City
State
ZIP
™
™
Plan Type
Network Health Together
(MassHealth)
Network Health Forward
(Commonwealth Care)
Referring provider information
Provider name
NPI #
Network Health provider ID # or billing ID #
Tax ID #
Provider phone
-
-
Provider fax
-
-
Provider address
City
State
ZIP
Treating provider information
Specialist name
Network Health provider ID # or billing ID #
Tax ID #
Specialist address
Specialty
City
State
ZIP
Specialist phone
-
-
Specialist fax
-
-
Contact name
Contact phone
Contact fax
-
-
-
-
Reasons for prior authorization request
Please check all that apply and include associated CPT codes.
Administer injectable drug at office or facility (have own supply)
Other Please specify.
CPT code(s)
Diagnosis
ICD-9 code
Diagnosis
Requested services
Number of visits requested
1
2
3
Other Please describe.
/
/
First date of services
or
Appointment not yet scheduled
Approved medical authorization valid for 90 days from date of issue unless otherwise specified.
2396A 02020
Attachment A
Network Health Provider Manual 2009
Form available at
Phone: 888-257-1985

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