Treatment Authorization Request (Tar) - County Medical Services Program (Cms)
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1TREATMENT AUTHORIZATION REQUEST (TAR)
COUNTY MEDICAL SERVICES PROGRAM (CMS)
Mark the appropriate boxes indicating which program will be utilized for the services requested.
URGENT REQUEST
RETRO TAR REQUEST
Please include all info required to substantiate medical necessity.
PATIENT INFORMATION
REFERRING PROVIDER INFORMATION Specialist
Yes or
No
Patient Name:_________________________________________________________
Name:______________________________________________________________
Address: _____________________________________________________________
Address: ____________________________________________________________
City/State/Zip: _______________________________________________________
City/State/Zip: _______________________________________________________
Phone Number: _______________________________________________________
Phone Number: ______________________________________________________
SSN: ___________________________ DOB: _______________________________
Clinic ID#: __________________________ Date: __________________________
Elig:__________________________through ________________________________
By: _________________________________________________________
(month)
(year)
(month)
(year)
(Print Physician’s Name)
SPECIALIST INFORMATION
NOTICE TO PROVIDERS
Services beyond those authorized in this referral must be
Name:________________________________________________________________
specifically authorized by CMS. The referral is valid only when
patient is certified. You may verify certificaton when the patient
Address: _____________________________________________________________
presents his/her identification card . The service must be provided
City/State/Zip: ________________________________________________________
prior to the expiration date noted below. Unauthorized services or
services not specifically noted will not be honored for payment.
Phone Number: _________________________Appt. Date: ___________________
SERVICES REQUESTED WITH THIS REFERRAL
:______________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
CPT Codes: ___________________________________________________________________ICD-9 Codes______________________________________________________
CLINICAL INFORMATION, including pertinent lab, x-ray and treatment to date:
________________________________________________________________
___________________________________________________________________________________________________________________________________________
Clinic MD Signature:__________________________________________________________
_____________________________________________________
Data Enclosed:
Lab Reports [
]
X-ray [ ]
Narrative Reports [
]
Med. Reports [
]
Other:_____________________________
WRITTEN FINDINGS THAT ARE A RESULT OF THE REFERRAL SHOULD BE PROMPTLY SENT TO THE PRIMARY CARE PROVIDER
TAR NUMBER:_____________________ BY:_______________________________________ EXP. DATE: ___________________________________
SERVICES AUTHORIZED: ____________________________________________________________________________________________________
THIS AREA FOR SPECIALIST RESPONSE: _____________________________________________________________________________________
__________________________________________________________________________________________________________________________
DATE:___________________________________________Specialist Signature:___________________________________________________________
FOR FURTHER INFORMATION CONTACT CMS Authorization Department at (858) 658-8650
Mail or Fax TAR to: CMS Authorizations PO Box 927110, San Diego, CA 92192
Fax TAR to: (855) 394-7927
HHSA: CMS-19 (4/15) - REQUEST FOR REFERRAL SERVICES
County of San Diego Health and Human Services Agency
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Parent category: Medical