Spine Referral For Neurosurgeon Or Orthopedic Priority Health

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Prior Authorization Form
NOTE: Refer to the Provider Manual for additional services requiring prior authorization
Reset Form
Fax form to: 616 942-0024
*
Spine Referral for Neurosurgeon or Orthopedic Surgeon Evaluation
*Only required for members 18 years of age and above.
Member
Last name: ______________________________________________
First name: ______________________________________
ID #: ____________________________________________________
DOB: ___________________________________________
Date of service: _________________________________________
Urgent request
Requesting provider: _____________________________________
Phone:
Fax: ___________________
Address: ________________________________________________
Contact name: ____________________________________
Servicing provider: _______________________________________
Phone:
Fax: ___________________
Address: ________________________________________________
Contact name: ____________________________________
Provider tax ID:
Primary diagnosis description:
Diagnosis code(s) (ICD-9):
Primary procedure description:
Procedure code(s) (CPT):
Clinical Indication
(1) Evidence of tumor, infection or fracture
Location:
Cervical
Thoracic
Lumbar
Level
(2) Acute weakness of arms or legs (paraparesis or unsteady gait)
Arm(s)
Affected arm(s)
Left
Right
Leg(s)
Affected leg(s)
Left
Right
Upper motor neuron signs (Babinski or Hoffman’s signs, clonus, hyperreflexia)
AND/OR
Loss of bladder or bowel control
AND/OR
Cord compression with decreased T1 signal changes, increased T2 signal changes, or signal changes at multiple cord
levels on MRI
(3) Cauda equina syndrome (new onset of bowel or bladder dysfunction with areflexia, asymmetric paraparesis)
(4) Follow-up to emergency or inpatient care for spine-related condition. Date of ER Visit or Inpatient Admit:
Surgeon name _______________________________________ Surgeon specialty__________________________________
(5) Patient has been evaluated by a Spine Center of Excellence (SCOE). Date of SCOE Evaluation:
Name of SCOE/provider________________________________ Provider specialty__________________________________
(6) Other indications not listed above
____________________________________________________________________________________________________
____________________________________________________________________________________________________
***All fields must be complete and legible for prior authorization review***
Print
Last Revision: August 2012

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