Form Um100 - Transplant Consult/testing Preauthorization Treatment Request Form
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PREAUTHORIZATION TREATMENT REQUEST
TRANSPLANT CONSULT/TESTING
URGENT (Three business days)
Routine
RETRO
(855) 883-1552
FAX TO:
PHONE: (888) 301-1228
Services for transplant patients are performed by both the transplant center and the primary care
provider. The referral specialist is responsible to inform the PCP of the patient status and proposed
interventions throughout the course of treatment.
*The PCP is responsible for maintaining communication with the transplant center.*
PATIENT INFORMATION
Date of Request:___________ Patient Name: __________
____________
_________________
CIN:_____________________
Last
First
Mailing Address:___________________________________________ City:______________________________ State: _______ Zip:_____________
D.O.B.____________________
Age:________
Diagnosis: ____________________________________
Dx Code: _______________________
Primary Care Provider Name:__________________________________________ Clinic Name:______________________________________________
PROVIDER INFORMATION
Ordering Provider:_________________________________
Provider Performing Services:__________________________________
___ Transplant Center
NPI_____________
___ Transplant Center
NPI_____________
___ PCP
TIN_____________
___ PCP
TIN_____________
___ Clinic
___ Clinic
Other: ______________
Other: ________________
Address:________________________________________
Address:________________________________________
City:_____________________ St:________ Zip:________
City:_____________________ St:_________ Zip:________
Phone:____________________ Fax:_________________
Phone:____________________ Fax:__________________
Office Contact:___________________________________
Office Contact:___________________________________
REQUEST FOR AUTHORIZATION
***** Include Transplant Center Orders*****
Date(s) of Services:_______________________________
Retro Date(s) of Service:____________________________
WHEN ADDING A PROCEDURE PLEASE MAKE SURE THAT THE CORRECT CODE IS INCLUDED.
Quantity: Code(s):
Requested Procedure(s):
Quantity: Code(s):
Requested Procedure(s):
OFFICE CONSULTS
Office Consult-New:
1)_____ _______________
Office visit- Established:
99205
99215
2) __________________
1)
__
2)
__
3)__________
3)____________________
LABS
86850-86901-
ABO- Type and Screen- x2
82105
Alpha Fetoprotein
86900
Blood Typing- Serum Antigen/Rbc
Alpha- 1 Antitrypsin total and
86904-86905
82103-82104
Antigen-
phenotype
FOR BMT
85004
CBC w/ diff (w/in 6 mos.)
86592
RPR- syphilis
85032
CBC w/ manual cell count
84153
PSA Total- for males >/= 40yrs age
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Parent category: Business