Ancillary Service Authorization Request Page 2

Codes and applicable modifiers:

Enter the valid HCPCS code for the item requested and modifier.

Modifier for contracted items as in contracts or for

Purchase Items = NU, Rental Items = RR

Quantity Requested:

Enter quantity of item or service requested.

Unit of Measure:

Enter units in accordance as utilized in billing process. (e.g. per

box, each, 100 calories or per pair)

Documents attached:

Mark the appropriate box to indicate if the required

documentation

is attached. (**Required documentation = See above)

If “Yes”, please specify:

Indicate what documentation is being submitted with the

request form

Other information:

Enter any comments or in the case of non-specific HCPCS codes

list the RETAILPRICE for the item. A description of the item

must accompany these requests and in certain items the

suppliers invoice may be requested.

Date:

Enter the date the request completed.

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Parent category: Medical