Prior Authorization Standard Request Form

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Fax: (844) 424-3976
Phone: (602) 586-1841
(
800) 564-5465
Prior Authorization
Standard Request Form
*For all Services Excluding DME/Medical Supplies, Home Health, PT,OT and ST
Requesting Provider Fax Number:
Date of Request: ____________________
Total Number of pages_______________
PLEASE NOTE: Processing time for a Standard Authorization Request is 14 Calendar Days.
PLEASE NOTE: Processing time for a Standard Request for Authorization is 14 calendar days.
If the member’s life or health is in serious jeopardy, please submit an
For urgent requests, please call 800-564-5465 to submit an authorization. This will ensure
Urgent Request by phone for optimal processing times.
optimal processing times.
Call us at 1-800-624-3879
Member Information
Member Name: _______________________________Member ID #:___________________ DOB:_________________
Other Insurance: Yes
No
If yes, please specify:
Phone #:________________
Ordering Physician Information
Requesting Provider Information
Requesting Physician Name: __________________________________
TIN/NPI#:________________
Physician Name:
Address:__________________________________________________ Phone #: _______________________________
Fax Number:
Request completed by:_______________________________________
Servicing Provider/Facility Information
Servicing Provider/Facility Name____________________________________
TIN/NPI#: _______________
Address: _________________________________________________ Phone #: ____________ Fax #: _____________
Inpatient Date of Service:_______________
Diagnosis Code(s):_________________________________________________________________________________
CPT Code(s):______________________________________________________________________________________
Patient History
Other Exams, tests, x-rays, MRI, etc:.___________________________________________________________________
Significant Signs and Symptoms:______________________________________________________________________
Duration of Symptoms:______________________________________________________________________________
Other Treatments performed:_________________________________________________________________________
Please include supporting documents which might include:

Required Documentation
Radiology
Physician Notes
 X-Rays
Lab Results
Specialist Consult Notes
Diagnostic Tests
Other
Other
Results
IMPORTANT: To prevent delays in processing time, please provide completed documentation specific to this
IMPORTANT: Failure to provide complete documentation specific to the request
request. Failure to do so may impact the final determination for this authorization.
will result in delayed processing times
Authorization does not guarantee payment. All authorizations are subject to member eligibility on the date of
Authorization does not guarantee payment. All authorizations are subject to member eligibility on the date of
service. If member is determined ineligible, the member may be responsible for these services. To ensure proper
service. If member is determined ineligible, the member may be responsible for these services. To ensure proper
payment for services rendered, referral provider/facility must verify eligibility on the date of service. Verify benefit
payment for services rendered, referral provider/facility must verify eligibility on the date of service. Verify
coverage in the benefit matrix located @
benefit coverage in the benefit matrix located in the Member Handbook.
Updated 01/15/2013

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