Transcription of PLEASE PRINT OR TYPE SECTION 1. IDENTIFYING …
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PLEASE PRINT OR TYPE SECTION 1. IDENTIFYING …
Phone Number:Fax Number:Phone Number:CPT/DRG Code: ICD/DSM Code:LWC FORM 1010 - REQUEST OF AUTHORIZATION/CARRIER OR SELF insured EMPLOYER RESPONSEP A T I E N TLast Name:First:Middle:Street Address, City, State, Zip: PLEASE PRINT OR TYPELast 4 Digits of Social Security Number:Date of Birth:Phone Number:Date of Injury:INFORMATION REQUIRED BY RULE TO BE INCLUDED WITH REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care ProviderEmail: SECTION 1. IDENTIFYING INFORMATION - To Be Filled Out By Health Care ProviderSECTION 2.
I hereby certify that additional information, pursuant to the determination of Medical Services Section, was SECTION 7. HEALTH CARE PROVIDER RESPONSE TO MEDICAL SERVICES DETERMINATION to the Carrier/Self Insured Employer on this the _____ day of _____ , _____ The required information of LAC40:2715(C) was provided
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