Transcription of Prior Authorization Request (PAR) Coversheet
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Prior Authorization Request (PAR) Coversheet
Expedited Request ? Initial Request Resubmission Request Note: Expedited requests require justification to meet expedited DateNumber of Pages (including Coversheet )For HCPCSE ntity Submitting Supplier Physician/Treating Practitioner (TP) Supplier NamePhysician/TP NameSupplier AddressPhysician/TP AddressSupplier PhonePhysician/TP PhoneSupplier Contact NamePhysician/TP FaxSupplier FaxPhysician/TP NPIS upplier NPIS upplier PTANB eneficiary NameMedicare NumberBeneficiary State of ResidenceBeneficiary Date of BirthFor additional information such as medical policy, please visit our websites for: Power Mobility Devices.
Title: Prior Authorization Request \(PAR\) Coversheet \(DME MAC Jurisdiction C\) Author: CGS - CH Subject: DME MAC JC Created Date: 1/2/2018 2:09:12 PM
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