General Information For Authorization Page 6

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Instructions to fill out the General Information for Authorization form, HCA 13-835
FIELD
NAME
ACTION
ALL FIELDS MUST BE TYPED.
26
Tooth or Quad#:
Enter the tooth or quad number as listed below:
(Required for dental requests).
QUAD
00 – full mouth
01 – upper arch
02 – lower arch
10 – upper right quadrant
20 – upper left quadrant
30 – lower left quadrant
40 – lower right quadrant
Tooth # 1-32, A-T, AS-TS, and 51-82
Enter appropriate diagnosis code for condition.
27
Diagnosis Code
28
Diagnosis name
Short description of the diagnosis.
29
Place of Service
Enter the appropriate two digit place of service code.
Place of
Service
Place of Service Name
Code(s)
1
Pharmacy
3
School
4
Homeless Shelter
5
Indian Health Service Free-standing Facility
6
Indian Health Service Provider-based Facility
7
Tribal 638 Free-standing Facility
8
Tribal 638 Provider-based Facility
9
Prison-Correctional Facility
11
Office
12
Home
13
Assisted Living Facility
14
Group Home
15
Mobile Unit
16
Temporary Lodging
17
Walk in Retail Health Clinic
20
Urgent Care Facility
21
Inpatient Hospital
22
Outpatient Hospital
23
Emergency Room – Hospital
24
Ambulatory Surgical Center
25
Birthing Center
26
Military Treatment Facility
31
Skilled Nursing Facility
32
Nursing Facility
33
Custodial Care Facility
34
Hospice
41
Ambulance - Land
42
Ambulance – Air or Water
49
Independent Clinic
50
Federally Qualified Health Center
51
Inpatient Psychiatric Facility
HCA 13-835 (11/16)

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