Transcription of PRIOR AUTHORIZATION REQUEST FORM - alliantplans.com
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PRIOR AUTHORIZATION REQUEST FORM - alliantplans.com
PRIOR AUTHORIZATION REQUEST form . Providers have access to submit PRIOR authorizations online. To register, visit DATE OF REQUEST : MM/DD/YYYY. SCHEDULED DATE OF SERVICE: MM/DD/YYYY. PROVIDER INFORMATION. Referring Physician Name: form Completed By: Phone Number: Fax Number: Patient Name: Member ID Number: ICD-10 code or Diagnosis: CPT: SERVICE INFORMATION. Provider Name: Type of Service (Please Select): Observation Inpatient Outpatient Ancillary PT OT ST Home Health Hospice DME HCPC(s):_____. Required for DME. CLINICAL INFORMATION. Please provide comments/clinical/supporting information to expedite the AUTHORIZATION : Physician Signature (Required): X. COMPLETED BY ALLIANT MEDICAL MANAGEMENT: AUTHORIZATION Number: Effective Date: Expires: Initial Inpatient LOS (if applicable): Amount of Outpatient services approved: Submit To Fax #: 866-370-5667 For Questions Call: 800-865-5922.
ahp prior authorization request form rev prior authorization request form date of request: mm/dd/yyyy provider information referring physician name:
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