Fillable Imaging Prior Authorization Request Form printable pdf download

Imaging Prior Authorization Request Form

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Imaging Prior Authorization Request Form

Fax: 313-745-0399

Medical Management Phone: 877-501-0958

Please answer all information completely. Failure to do so may delay the determination of your request. If not applicable, use N/A

Date of Request:

_____________

Date of Service:

_____________

Member’s Name: ________________________________________________

DOB: ________________

DMC Care ID#: ______________________________

Other Insurance: _____________________________________

Requesting Physician: ____________________________________ Specialty: ___________________________________

Contact Person: _______________________________

Phone#: _________________ Fax#: ___________________

Imaging Facility Name: ________________________________________

Phone#: _______________________________

Address: ______________________________________________________

Fax#: ___________________________

Provider Tax ID #: ____________________________

NPI #: _______________________

Diagnosis: ____________________________________________

ICD-10 Code:__________________________________

Procedure: ____________________________________________

CPT-4 Code:

___________________________________

*MUST INCLUDE CURRENT CLINICAL AND THE FOLLOWING INFORMATION:

Symptoms/Complaints

Onset/Duration

Physical Exam Findings

Prior Test/Treatments/Biopsy

Results

Test/Treatment/Surgery/Medication

Date(s)

MEDICAL MANAGEMENT USE ONLY:

Denied

Approved:

Authorization#: ___________________

No Authorization Required

Staff Initials: _____________________

Date: ________________

PROVIDER MUST NOTIFY MEMBER: CO- PAYS, COINSURANCE & DEDUCTIBLES WILL APPLY FOR THIS SERVICE

NOT G

. P

UTHORIZATION

OES

UARANTEE

AYMENT

EPENDENT ON

LIGIBILITY ON

ATE OF

ERVICE

AUTHORIZATION IS NOT INCLUSIVE OF GAP EXCEPTION

CONFIDENTIALITY NOTICE: This message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and/or privileged

information. If you are not the intended recipient(s), you are hereby notified that any dissemination, unauthorized review, use, disclosure or distribution of this

communication and any materials contained in any attachments is prohibited. If you receive this message in error, or are not the intended recipient(s), please immediately

notify the sender and destroy all copies of the original message, including attachments.

DMC Care 2016

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