Transcription of ***PRIOR AUTHORIZATION IS NOT A GUARANTEE ... - Better …
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***PRIOR AUTHORIZATION IS NOT A GUARANTEE ... - Better …
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: _____. REFERRING PHYSICIAN TELEPHONE: (____)_____ _____. REFERRING PHYSICIAN FAX NUMBER: (____)_____ _____. mexd Request Type: Standard Expedited/Urgent By checking this box I certify that applying the standard review time frame may seriously jeopardize the member's life, health, or ability to regain maximum function. You may call our Pre-Certification department and advise the request is Expedited/Urgent at 1-877-915-0551, option 2.
Member Name: _____ Circle Plan Name: Simply Better Clear Health Health Plan ID #: _____ Member DOB: _____/_____/_____ Phone: (____)_____-_____
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