Insurance Preauthorization Request Form

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Insurance Preauthorization Request
Doctor
Date
Patient #
Computer #
Case type
Patient Name
D O B
Insured’s name
D O B
Relationship
Since (Date)
Injured/ill since
Employer
Phone
Address
Supervisor
City
State
Zip
Note
Insurance
Phone
Company
Address
Insured’s
ID#
City
State
Zip
Group #
Contact
Title
Phone
Claim #
Notes
Pre-Authorization Request
Initial Care
Update Care
Primary Insurance
Workers Compensation Insurance
Diagnosis
Treatment Requested
Treatment start date
Treatment end date
Treatment particulars; (Number & frequency of visits, etc.)
Additional requirements; (Traction, Ultrasound, Physiotherapy, Exercise, Diet, etc.)
Comments and Notes
Doctor’s Signature
Address & Contact details

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