PRIOR AUTHORIZATION FAX REQUEST FORM
PRIOR AUTHORIZATION FAX REQUEST form . Fax completed REQUEST to: (866) 370-5667 *Required Fields If you need assistance please call: (800) 865-5922. TODAY'S DATE: _____________________________ SCHEDULED DATE OF SERVICE: ___________________________________. *CONTACT NAME: ________________________________________ ________________________________________ ______________. *CONTACT PHONE: ____________________________________ *CONTACT FAX: _______________________________________. __. PROVIDER INFORMATION. *Provider Name: ________________________________________ ________________________________________ _________. Provider NPI: _______________________________________ Provider TIN: ________________________________________ . Provider Address: ________________________________________ ________________________________________ ________. FACILITY INFORMATION. Facility Name: ________________________________________ ________________________________________ ___________. Facility NPI: ________________________________________ Facility TIN: ________________________________________ _.
ap s prior autoriation reuest form octoer î ì í ô prior authorization fax request form today's date: _____ scheduled date of service: _____ fax completed request to: (866) 370-5667
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