REQUEST FOR PRIOR AUTHORIZATION Please FAX …

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REQUEST FOR PRIOR AUTHORIZATIONFAX (559) 224-2405 or (559) 224-9746PHONE (559) 228-5400 or (800) 652-2900OAqua TherapyOIntensity Modulated Radiation Therapy (IMRT)OBreastfeeding Medicine ReferralOM2A Video Capsule EndoscopyOBalance & Dizziness ReferralOMRI, MRA, CT & Pet ScansOColonoscopy; EGDONutrition Consult for Chronic Disease (CMC)OCosmetic/Reconstructive SurgeryOObesity - Referral to General SurgeonODME Purchase over $200OObesity SurgeryODME RentalOOut-of-Plan ProviderOEndocrinologist Visit (Type II Diabetes)OPlastic Surgery ReferralOGenetic TestingOSleep StudiesOHome Health Home in conjunction with Health Plan ProgramsOInfusions - Ambulatory (See reverse side of this form)OWeight Management Program ReferralOInjections: Self-injectables; In-office injectablesOWound Care - Facility Based(See reverse side of this form for more information)OO NON-UR

REQUEST FOR PRIOR AUTHORIZATION Please FAX completed form with related clinical information attached to (833) 853-8549 For questions, please contact …

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