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Initial Authorization Request Form - Maine

___New PA Request ___MEDICALLY URGENT Request prior Authorization Revised: 08/27/2018 PA Fax Date: Submitter Name:_____ Submitter Telephone #: Submitter Fax #: Submitting Provider Return Address: Section 1: (See Section 3 for instructions) 1. Submitting Provider Name and NPI or API 2. Member Name and ID# 3. Authorization dates From To 4. Diagnosis Codes ICD-10 (enter all applicable) Principal ..; . Secondary Admitting . Code Modifier Unit(s) Description or NDC Code 5. Service Procedure Codes/ J-Codes/ Description or NDC (if applicable) If prior authorizing several service codes please attach them on a separate form 6.

Section 2: Purpose- This form MUST be used when mailing or faxing a new prior authorization request. When mailing your request, color copies will be easier to process. Write only within the fields and clearly circle only one type of PA request.

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