PRIOR AUTHORIZATION FAX REQUEST FORM

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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: ________________________________________ .

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 If you need assistance please call: (800) 865-5922

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