Prior Auth Request Form 2013 - affinitymd.com

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Prior Authorization Request Form Please check type of Request : q Routine (Non-urgent services) q Expedited (Medicare only Care required within 72 hours). q Urgent/Concurrent (Care required within 24 hours) q Submission of additional clinical information Patient Name: DOB: Daytime Phone: Health Plan: Health Plan ID#: Address: City: State: Zip: Facility/Provider/Service Information: Referring Provider: q PCP q SPEC Phone: Provider Signature: Date: Fax: q Office q Outpatient q Inpatient Admit q Diagnostics q DME q Home Health q Injectables q Other ____________. Requested Provider/Facility: Requested Physician/Specialist: Name: First Name: Last Name: Address: Phone: Fax: Requested Service(s): REQUIRED: ICD10 Code(s). CPT Codes(s). Diagnosis/Clinical Problem: Patient Name auth #. Clinical History/Date of Onset: Prior Treatment: Relevant Diagnostic Testing: Form Submitted by: ________________________________________ __ Date _____________________ Phone: _____________________________.

Title: Microsoft Word - Prior Auth Request Form 2013.docx Author: Glady Macalino Calalay Created Date: 20130110211302Z

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