STATE OF COLORADO
DEPARTMENT OF
HEALTH CARE POLICY AND FINANCING
INVOICE//PAT. ACCOUNT NUMBER
MEDICAID PRIOR AUTHORIZATION REQUEST
(PAR)
DOES CLIENT HAVE PRIMARY
INSURANCE?
YES
NO
To avoid delay, please answer all questions completely.
1. CLIENT NAME (Last, First, Middle Initial)
2. CLIENT IDENTIFICATION NUMBER
3. SEX
4. DATE OF BIRTH (MMDDYY)
M
F
5. CLIENT ADDRESS (Street, City, State, ZIP Code)
6. CLIENT TELEPHONE NUMBER
(
)
*
9. DOES CLIENT RESIDE IN A
10. GROUP HOME NAME -
7. PRIOR AUTHORIZATION NUMBER
8. DATES COVERED BY THIS REQUEST
NURSING FACILITY?
IF PATIENT RESIDES IN A GROUP HOME
SYSTEM ASSIGNED
FROM (MMDDYY)
THROUGH (MMDDYY)
YES
NO
11. ICD-10-CM DIAGNOSIS CODE and DESCRIPTION (Must inc lude Diagnosis Code and Description, Prognosis, Clinical Information and Other Medications presently prescribed)
12. REQUESTING AUTHORIZATION FOR REPAIRS
EQUIPMENT MUST BE OWNED BY THE CLIENT -
THE SERIAL NUMBER MUST BE ENTERED
13. IND ICATE LENGTH OF NECESSITY (IN MONTHS AND YEARS) I.E.,
HOW LONG WILL THIS EQUIPMENT BE NEEDED?
14. ESTIMATED COST OF EQUIPMENT
SERVICES TO BE AUTHO RIZE D
15.
16.
17.
18.
19.
20.
AUTHORIZED NO. OF
REQUESTED
APPROVED/DENIED
SERVICES (LEAVE
DESCRIBE THE PROCEDURE OR SUPPLY TO BE PROVIDED — INCLUDE MODEL NUMBER FOR DME
NUMBER OF
**
LINE NO.
PROCEDURE OR SUPPLY CODE
**
SERVICES
(LEAVE BLANK
)
PURCHASE OR SERIAL NUMBER FOR REPAIR
BLANK
)
01
02
03
04
05
21. PRIMARY CARE PHYSICIAN (PCP) NAME
22. PRIMARY CARE PHYSICIAN ADDRESS (Street, City, State, ZIP code)
TELEPHONE NUMBER
23. PCP PROVIDER NUMBER
(
)
24. NAME AND ADDRESS OF PHYSICIAN REFERRING FOR PRIOR AUTHORIZATION
25. NAME AND ADDRESS OF PROVIDER WHO WILL BILL SERVICE
26. REQUESTING PHYSIC IAN SIGNATURE
27. DATE SIGNED
TELEPHONE NUMBER
28. REQUESTING PHYSIC IAN PROVIDER NUMBER
TELEPHONE NUMBER
29. BILLING PROVIDER NUMBER
(
)
(
)
If services are provided according to the manner prescribed by State of Colorado Laws and Regulations, reimbursement will be provided for authorized services following submission of an
appropriately completed Medicaid claim.
**
30. COMMENTS
ATTACH COPY OF THIS PAR TO CLAIM(S) **
**
**
**
SIGNATURE OF STATE AGENCY REPRESENTATIVE
DATE
31. PA NUMBER BEING REVISED
*
**
THE ASSIGNED PAR NUMBER APPEARS ON THE PAR LETTER. ENTER THE PAR NUMBER FROM THE LETTER ON THE CLAIM WHEN BILLING FOR THE SERVICES.
THESE FIELDS ARE COMPLETED BY THE AUTHORIZING AGENT
FORM NO. 10013 (REV. 0811)
COL — 106