Prior Authorization Request (PAR) Coversheet

← Back to document page

Expedited Request ? Initial Request Resubmission Request Note: Expedited requests require justification to meet expedited DateNumber of Pages (including Coversheet )For HCPCSEntity Submitting Supplier Physician/Treating Practitioner (TP) Supplier NamePhysician/TP NameSupplier AddressPhysician/TP AddressSupplier PhonePhysician/TP PhoneSupplier Contact NamePhysician/TP FaxSupplier FaxPhysician/TP NPISupplier NPISupplier PTANBeneficiary NameMedicare NumberBeneficiary State of ResidenceBeneficiary Date of BirthFor additional information such as medical policy, please visit our websites for.

Title: Prior Authorization Request \(PAR\) Coversheet \(DME MAC Jurisdiction C\) Author: CGS - CH Subject: DME MAC JC Created Date: 1/2/2018 2:09:12 PM

  Request, Authorization, Prior, Prior authorization request