Medical Prior Authorization Form

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Medical Prior Authorization Form
Please complete this form in its entirety. For a list of all services that require authorization,
please refer to the following:
Date: _____________________ Contact Person:
______________________________________________
Telephone Number: ________________________ Fax Number: _________________________
Requesting Provider: ____________________________ NPI___________________ TIN_____________________
Reerrr
Servicing Provider: ______________________________ NPI___________________ TIN_____________________
Facility: _______________________________________NPI___________________ TIN______________________
Is the Servicing Provider In-Network? [ ] yes
[ ] no
Member Name______________________ Member ID Number_________________________
Member D.O.B.___________________________
Type of service requested: ____________________________________________________________________
*Diagnosis Code(s): ___________________________________________________________________________
*CPT/HPC Code(s):____________________________________________________________________________
*Date of Service: _____________________________________________________________________________
Number of Visits: ___________________________________________________________________________
Note: In order to process your request in a timely manner, please submit any pertinent clinical
information to support the request for services. Please fax form to 855-258-5466.

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