Home Care Iv Infusion Services Pa Form - Priority Health
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1Authorization Form
IV Infusion Services
Fax Form To: 616 975-8885
Reset Form
Attn: Home Health Care
Member
Last Name: ___________________________________
First Name: ______________________________
ID #: _________________________________________
DOB: ___________________________________
Diagnosis/Condition: ______________________________________________________________________
Medication/Solution Requested:
Code:
______________________________________________________
________________________________________________
______________________________________________________
________________________________________________
______________________________________________________
________________________________________________
______________________________________________________
________________________________________________
RN visits provided by Home Infusion Provider? Yes
No
RN
_______ + _______ = _______
(automatic auth will be 3 to teach then one weekly)
Provider of RN care: _______________________________________________________________________________
Duration of treatment:
Start Date: _______________
End Date: _______________
Please note: This process does not replace medication authorizations that require prior authorization
through the pharmacy department.
Requesting Physician Information:
Provider Name: _____________________________________ Phone: ____________________________________
Contact Name: _____________________________________
Requesting IV Infusion Provider Information:
Company Name: ____________________________________ Phone: _____________________ Ext: _____________
Contact Name:______________________________________ Tax ID#: _____________________________________
Authorization Process for Home Care Services:
Vendor receives an order for home care therapy.
Vendor will complete this authorization form and fax it to 616 975-8885. Include a call back number and contact name.
Authorization confirmation will be available within 3 business days via Auth Inquiry in the online Provider Center at
. Once logged in to the Provider Center, select Auth Inquiry from the tools on the right. Need a login for
our Provider Center? Contact the Provider Helpline at 800 942-4765.
This facsimile transmission contains confidential information. The information is intended solely for use by the individual entity named
as the recipient hereof. If you are not the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of
this transmission is prohibited. If you have received this transmission in error, please notify us by telephone immediately so we may
arrange to retrieve this transmission at no cost to you.
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4413 08/11
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Parent category: Medical