Department Of Insurance Prior Authorization Form In Page 2

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Indiana Register
Section IV – Provider Information
Requesting Provider or Facility
Service Provider or Facility
Name
Name
NPI #
Specialty
NPI #
Specialty
Phone
Fax
Phone
Fax
(
)
(
)
(
)
(
)
Contact Name and Phone
Name of Primary Care Provider (see instructions)
Requesting Provider's signature and date (if required)
Phone
Fax
(
)
(
)
Section V – Services Requested (with CPT, CDT, or HCPCS Code) and Supporting Diagnoses (with ICD
Code)
Start
End
Diagnosis Description (ICD
Planned Service or Procedure
Code
Code
Date
Date
Version _____), if available
/ /
/ /
/ /
/ /
/ /
/ /
Inpatient
Outpatient
Provider Office
Observation
Home
Day Surgery
Other (specify)
Physical Therapy
Occupational Therapy
Speech Therapy
Cardiac Rehab
Mental Health/Substance Abuse
Number of sessions
Duration
Frequency
Other
Home Health (MD signed Order attached?
Yes
No) (Nursing Assessment attached?
Yes
No)
Number of visits requested
Duration
Frequency
Other
DME (MD signed order attached?
Yes
No) (Medicaid only: Title 19 Certification attached?
Yes
No)
Equipment/supplies (Include any HCPCS Codes)
Duration
Section VI – Clinical Documentation (See Instructions Page, Section VI)
An issuer needing more information may call the requesting provider or authorized representative
directly at: (
) ______ - _________ (ext. _____) or via email at _______________________. Preferred
method of contact is
phone or
email.
Section VII – Reason for Denial or Partial Denial (To be completed by the issuer)
PRIOR AUTHORIZATION REQUEST FORM FOR HEALTH CARE SERVICES for use in Indiana
Please read all instructions before completing the form.
Do not send the completed form to the Indiana Department of Insurance or to the patient's or subscriber's
employer.
Date: Jan 20,2017 9:24:56PM EST
DIN: 20150304-IR-760150057NRA
Page 2

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