Medical Management Authorization Request Form printable pdf download

Indiana University Health Medical Management

Authorization Request Form

Forward completed form via FAX to IUHMM at (317) 962-6219 or (317) 962-4005

REQUESTING PHYSICIAN INFORMATION

REQUESTING VENDOR INFORMATION

Ordering MD: ____________________________________

Vendor: ________________________________________

**TAX ID: ______________________________________

Address: _______________________________________

Phone: __________________ Fax: _________________

Phone: _________________ Fax: __________________

Contact: ________________________________________

MEMBER INFORMATION

******IUHMM USE ONLY******

Name: _______________________________________

AUTHORIZATION NUMBER________________________

□ Services APPROVED As Requested

ID#: _______________________________

□ Request MODIFIED (see below for detail)

DOB: ______/______/______

□ Request DENIED, Letter To Follow

SS#: ________/________/________

Modifications

Phone: ______________________________

Made:______________________________

IUHMM Staff:____________________________________

Date:___________________________________________

Date of

CPT or

Requested Service

Place of Service INP

Units

Diagnosis / ICD9

Service

HCPC

Code

OBS

CLINICAL SUMMARY (Form will be rejected if CLINICAL SUMMARY is NOT completed). (Send attachments, if needed).

________________________________________________________________________________________

SIGNATURE OF REQUESTING MD: ____________________________________ DATE: ___________________________

Medical Management Authorization Request Form