Transcription of ***PRIOR AUTHORIZATION IS NOT A GUARANTEE …
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Example: dental hygienist
***PRIOR AUTHORIZATION IS NOT A GUARANTEE …
REQUEST FOR SERVICES REQUIRING PRIOR DME/HH/INFUSION SRVC. AUTHORIZATION . FAX 1-800-283-2117 FAX: 1-855-461-0629. TELEPHONE NUMBER 1-877-915-0551, OPTION 2. Member Name: _____PHONEREFERRED TO: _____. Circle Plan Name: Simply Better Clear Health SPECIALTY :___ _____. Health Plan ID #: _____ APPOINTMENT DATE: _____. Member DOB: _____/_____/_____ Phone: (____)_____-_____ REFERRED TO : PROVIDER ID #: _____. PCP Name: _____ REFERRED TO FAX #: _(_____)_____. PCP ID #: _____ Phone: (____)_____-_____ DIAGNOSIS (ICD): _____, _____, _____, _____. REFERRING PHYSICIAN NAME: _____ CPT CODES: _____, _____, _____, _____. CONTACT PERSON:_____ REASON FOR REFERRAL: _____.
Member Name: _____ Circle Plan Name: Simply Better Clear Health Health Plan ID #: _____ Member DOB: _____/_____/_____ Phone: (____)_____-_____
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