Transcription of PLEASE PRINT OR TYPE SECTION 1. IDENTIFYING …
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Example: tourism industry
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. REQUEST FOR AUTHORIZATION - To Be Filled Out By Health Care ProviderEmployers Name:Street Address, City, State, Zip:CARRIERName:Phone Number:Diagnosis: Requested Treatment or Testing (Attach Supplement If Needed):Reason for Treatment or Testing (Attach Supplement If Needed):PROVIDERS treet Address, City, State Zip: Fax Number:Request
PLEASE PRINT OR TYPE Last 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 Provider Email: SECTION 1. IDENTIFYING INFORMATION - To Be Filled Out By Health Care Provider SECTION 2.
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