Transcription of QAF-NO AUTHORIZATION REQUIRED FORM …
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QAF-NO AUTHORIZATION REQUIRED FORM …
Effective Date: 8/1/2017. QAF-NO AUTHORIZATION REQUIRED FORM (MEDICAID). For participating Primary Care Providers only to refer to a participating specialist or diagnostic center for the codes listed below Do not use for Hospitals, ASC's or for Prenatal care visits/treatment. **VALID FOR 90 DAYS**. For questions, please call 1-877-915-0551, Prompt 2. Member Name: ID#: DOB: Date: Phone: PCP Name: Phone: Fax: Referred to Specialist Name: Extremities Studies, choose: q RUE q LUE q RLE q LLE q Bilat UE q Bilat LE. Specialist Address (Street, City, Zip): Diagnosis Code(s) ( REQUIRED ): Provider Signature ( REQUIRED ): SPECIALIST OFFICE VISITS DERMATOLOGY CONT.
Send Claims to: Simply Healthcare Plans, Inc./CHA, Attn: Claims, P. O. Box 21535, Eagan, MN 55121, Electronic Submission #20488 (EMDEON). Claims are …
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