Transcription of PLEASE READ CAREFULLY THE FOLLOWING …
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PLEASE READ CAREFULLY THE FOLLOWING …
Patient's Name: ..Social Security No.: .. address : ..Employer's Name: .. address : .. Insurance Carrier's Name: .. address : .. Attending Doctor's Name: .. address : .. Individual Provider's WCB Authorization No.: .. Telephone No.: .. Fax No.: .. Authorization Requested: Carrier Response: if any service is denied, explain on reverse. Diagnostic Tests: Therapy (including Post Operative): Surgery: Treatment: Medical Treatment Guidelines Procedures Requiring Pre-Authorization (Complete Guideline Reference for each item checked, if necessary.)
Providers must complete Part A below indicating that the request was sent to the insurer/self-insurer's designated fax or email address (see Board's URL address below*), unless the provider is not equipped to send or receive email or fax (complete "C" below).
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