Form Ddd-1662a - Prior Authorization

Download a blank fillable Form Ddd-1662a - Prior Authorization in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Ddd-1662a - Prior Authorization with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1662A FORFF (9-17)
Division of Developmental Disabilities
Health Care Services
PRIOR AUTHORIZATION
FAX TO: (602) 253-9083
TO BE COMPLETED BY PROVIDER
MEMBER’S NAME (Last, First, M.I.)
AHCCCS ID NUMBER
DATE OF BIRTH
DATE
Cerebral Palsy
Autism
Cognitive/Intellectual Disability
Epilepsy
DIAGNOSIS:
:
Additional Diagnosis (Specify)
DIAGNOSIS CODE(S):
SUPPORT COORDINATOR’S NAME
PHONE NUMBER
PROVIDER/FACILITY NAME
PROVIDER REPRESENTATIVE NAME
PHONE NUMBER
FAX NUMBER
VENDOR ADDRESS (No., Street, City, State, ZIP Code)
From:
Thru:
PROVIDER NPI
DATE OF SERVICE:
MODIFIER
DESCRIPTION/
CHECK IF ONE
SERVICE CODE
SCRIPT DATE
UNIT(S)/MONTH
UNIT(S)/YEAR
CODE
REASON
TIME PURCHASE
TO BE COMPLETED BY PRIOR AUTHORIZATION UNIT
DATE PACKET RECEIVED BY
APPROVED
HEALTH CARE SERVICES
Yes – Authorization Number:
No (incomplete form, non covered service, not medically necessary, Other see comments)
APPROVED BY (Please Print)
APPROVED BY SIGNATURE
DATE
ADDITIONAL COMMENTS:
See reverse for EOE/ADA/LEP/GINA disclosures

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Prior Authorization Form - Medicare Administrative Prior Authorization For Part B/d Coverage Prior Authorization Form - Medicare Administrative Prior Authorization For Part B/d Coverage Business
Form F-11035 - Prior Authorization Dental Request Form (pa/drf) Form F-11035 - Prior Authorization Dental Request Form (pa/drf) Medical
Form F-11018 - Prior Authorization Request Form (pa/rf) Form F-11018 - Prior Authorization Request Form (pa/rf) Medical
Form 61-211 - Prior Authorization Request Form Form 61-211 - Prior Authorization Request Form Business
Form F-11092 - Prior Authorization / Preferred Drug List (pa/pdl) For Growth Hormone Drugs Form F-11092 - Prior Authorization / Preferred Drug List (pa/pdl) For Growth Hormone Drugs Business
Form F-11304 - Prior Authorization/preferred Drug List (pa/pdl) For Cytokine Form F-11304 - Prior Authorization/preferred Drug List (pa/pdl) For Cytokine Medical
Form F-11035 - Prior Authorization/preferred Drug List (pa/pdl) For Cytokine Form F-11035 - Prior Authorization/preferred Drug List (pa/pdl) For Cytokine Medical
Form F-11078 - Prior Authorization / Preferred Drug List (pa/pdl) For Proton Pump Inhibitor (ppi) Capsules And Tablets Form F-11078 - Prior Authorization / Preferred Drug List (pa/pdl) For Proton Pump Inhibitor (ppi) Capsules And Tablets Medical
Form F-11077 - Prior Authorization / Preferred Drug List For Non-steroidal Anti-inflammatory Drugs Form F-11077 - Prior Authorization / Preferred Drug List For Non-steroidal Anti-inflammatory Drugs Medical
Form F-00080 - Prior Authorization / Preferred Drug List (pa/pdl) For Symlin Form F-00080 - Prior Authorization / Preferred Drug List (pa/pdl) For Symlin Medical

Related Categories

Parent category: Legal
Download
Go
Page of 2