*REQUIRED FIELDS Pre-Authorization Request Form

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URGENCY OF Request : Standard 5 days Urgent 3 days Emergency 24 hours KERN LEGACY HEALTH PLANS Employee and Retiree Health Plan Options Pre-Authorization Request form 1115 Truxtun Ave, 1st Floor | Bakersfield CA 93301 | Ph: 661 868-3280 |UM Fax: 661 868-3291 | Kern Legacy Share Select | Kern Legacy Network Plus authorization form Revised December 7, 2018 Fax Request to *REQUIRED FIELDS Patient Information Last Name*: First Name*: Suffix: MI: Sex*: M F Member ID*: DOB*: PCP*: Other Health Coverage*: No Yes Street Address: City/State/Zip: Phone*: Subscriber Information (if the patient is a minor) Last Name: First Name: Relationship to Patient: Provider Information Requesting Physician*: NPI*: Phone*: Provider Signature*: Date*: Fax*: Mark the Kern Legacy Health Plan that your patient is enrolled in*: Type of Pre-Authorization Request : Kern Legacy Share Select Kern Legacy Network Plus Outpatient Inpatient There is NO Out-of-Network Benefit.

All fields on the form with an asterisk (*) must be filled in for the request form to be considered complete and clinical documentation to establish the medical necessity for requested services must be attached.

  Form, Request, Authorization, Pre authorization request form