Transcription of General Information for Authorization
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General Information for Authorization
General Information for Authorization Org 1. Service Type 2. Client Information Name 3. Client ID 4. Living Arrangements 5. Reference Auth # 6. Provider Information Requesting NPI # 7. Requesting Fax # 8. Billing NPI # 9.
General Information for Authorization Org . 1. Service Type . 2. Client Information . Name Client ID Living Arrangements Reference Auth # Provider Information . Requesting NPI # Requesting Fax # Billing NPI # 9. Name . 10. Referring NPI # Referring Fax # Service Start Date: 14. Service Request Information Description of service being requested ...
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