General Information For Authorization
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7General Information for Authorization
Org
Service Type
1.
2.
Client Information
Name
Client ID
3.
4.
Living Arrangements
Reference Auth #
5.
6.
Provider Information
Requesting NPI #
Requesting Fax #
7.
8.
Billing NPI #
Name
9.
10.
Referring NPI #
Referring Fax #
11.
12.
Service Start
14.
13.
Date:
Service Request Information
Description of service being requested:
16.
17.
15.
19.
18. Serial/NEA or MEA #
20. Code
21. National
22. Mod
23. # Units/Days
24. $ Amount
25. Part #
26. Tooth
r
Code
Requested
or Quad #
Qualifie
Requested
(DME Only)
Medical Information
Diagnosis Code
Diagnosis name
27.
28.
Place of Service Code
29.
30. Comments:
Please fax this form and any supporting documents to 1-866-668-1214.
The material in this facsimile transmission is intended only for the use of the individual to who it is addressed and may contain information that is
confidential, privileged, and exempt from disclosure under applicable law. HIPAA Compliance: Unless otherwise authorized in writing by the patient,
protected health information will only be used to provide treatment, to seek insurance payment, or to perform other specific health care operations.
HCA 13-835 (11/16)
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