Transcription of REQUEST FOR PRIOR AUTHORIZATION
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REQUEST FOR PRIOR AUTHORIZATION
Please check health PlanOAetnaOCignaOAetna Golden medicare PlanOHealth NetOBlue Shield 65 PlusOHealth Net Seniority PlusOBlue Shield Access PlusOPacifiCareOCalifornia CareOSecure HorizonsOO Nutrition Consult for Chronic Disease (CMC)OOOOOOOOOOOOOO Breastfeeding Medicine ReferralOOOP atient Name: LastFirstMIDate of Birth(Mo/Day/Yr) #Gender: MFOther Insurance?Name of Carrier?Job RelatedMVAA ccidentPregnancy Related?YesNoYesNoYesNoYesNoYesNoTax ID#TelephoneFaxName of PCPDateAddressFaxNoAnesthesiologist Required? :YesNoName:Name:Tentative Date of Service/Admission:ICD-9 Codes(required)Diagnosis Description:Date of Onset/InjuryCPT/HCPC Codes(required)# of Days/Visits:Comments:EFFECTIVE 4/01/2009: Within 5 days before the actual date of service, provider MUST confirm that the member's health plan coverage is still in the exception of urgent requests, it is recommended that you do not schedule appoint
O Aetna O Cigna O Aetna Golden Medicare Plan O Health Net O Blue Shield 65 Plus O Health Net Seniority Plus O Blue Shield Access Plus O PacifiCare
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