Authorization Request Form Page 2

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AUTHORIZATION REQUEST
Instructions for Completing the Authorization Form
Field Name
Description
S
1 – This section is completed by the requesting physician to provide information about the
ECTION
patient
Patient Name
Enter the patient’s name (first name followed by last name) for whom services
are requested
Date of Birth
Enter the patient’s date of birth
Sex
Check the appropriate box for the patient’s gender
Address
Enter the patient’s current address
Phone
Enter the patient’s current phone number
VMC Medical Record #
Enter the patient’s Medi-Cal number, VMC number, or Social Security number (if
Commercial).
Health Plan ID #
Diagnosis.
Enter the patient’s diagnosis or ICD9 Code.
ICD9 Code
Section 2 – This section is completed by the requesting physician to provide information about the
services ordered for the patient.
Location
Check the appropriate box for the location of the services: INPATIENT,
OUTPATIENT, OTHER (Please specifiy)
Type Service
Check the appropriate box for the type of service required: EMERGENCY,
URGENT, ROUTINE, or RETROSPECTIVE.
Program/Line of Business
Check the type of program in which the member is enrolled: Employer Group,
Covered CA/Individual & Family, SCFHP Medi-Cal, SCFHP HK.
Requested Provider
Enter the information (Name, Location, Phone #, and Fax #) of the requested
provider that the referring physician is recommending
Section 3 – This section is completed by the requesting physician to indicate the services required.
CPT4 or HCPC
Enter the appropriate CPT4 or HCPC code for the procedure requested
Quantity
Enter the number of procedures/treatments requested
Length of Need
Enter the amount of time the procedure/treatment is required
Specific Services Requested
Enter the specific information regarding the services required
Medical Justification for
Enter the medical information to indicate the need for the procedure/treatment
Request
Section 4 – This section is completed by the requesting provider.
Requesting Provider
Print the name of the requesting provider
Signature
The requesting provider must sign the treatment authorization request.
Date
Indicate the date when the requesting provider signs the request.
VHP Provider Manual – TAR Instructions

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