Neighborhood Health Plan Certificate Of Medical Necessity Prior Authorization Form

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Certificate of Medical Necessity
Prior Authorization Form
Page 1 of 2
Please return completed form to the Utilization Management Department at (401)459 -6023.
Please refer to Neighborhood’s Clinical Medical Policy which is available on our Neighborhood web site,
for more detailed information about this benefit, authorization requirements, and coverage criteria.
MEMBER INFORMATION
Member’s Name:
Member’s ID #:
Member’s DOB:
PROVIDER INFORMATION
Provider’s Name:
Supplier ID or NPI #:
Date Request Sent:
Date of Service:
Previous Auth #:
Place of Service (City/Town)/Facility:
Provider Contact and Phone #:
Provider’s Fax #:
Ordering MD:
CLINICAL INFORMATION
CPT Code:
Units:
CPT Code:
Units:
Diagnosis:
Diagnosis Code:
NOTE: For Absorbent Products (diapers), complete first page only.
Medical/Surgical History
Dates
Requested equipment (to include all
Size
Quantity
Date of Service
Rent or Purchase
accessories). May attach list.
Duration of need
_____ Months
1 year
Indefinite
Other
Prognosis
Indicate status of condition:
Permanent
Progressive
Temporary, full recovery expected
Ordering practitioner signature _________________________________________ Date________________________
Neighborhood Health Plan of Rhode Island
●
●
●
910 Douglas Pike
Smithfield, RI 02917
Tel. 401-459-6060
Fax 401-459-6023
Updated 7/2011, 7/2012, Reviewed 6/2013, 2/2016

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