Transcription of REQUEST FOR PRIOR AUTHORIZATION
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REQUEST FOR PRIOR AUTHORIZATION
OAetnaOCignaOSecure HorizonsOAetna Golden medicare PlanOHealth NetOBlue Shield 65 PlusOHealth Net Seniority PlusOBlue Shield Access PlusOHumana medicare AdvantageOCalifornia CareOPacifiCareO Breastfeeding Medicine ReferralOOOOO Nutrition Consult for Chronic Disease (CMC)OOOOOOOOOOOOOO NON-URGENT for routine, elective servicePatient Name: LastFirstMIDate of Birth(Mo/Day/Yr) #Gender: MFOther Insurance? Name of Carrier?Job RelatedMVAA ccidentPregnancy Related?YesNoYesNoYesNoYesNoYesTax ID#TelephoneFaxName of PCPDateAddressFaxNoAnesthesiologist Required? : Yes NoName:Name:Tentative Date of Service/Admission:ICD-9 Codes(required)Diagnosis Description:Date of Onset/InjuryCPT/HCPC Codes(required)# of Days/Visits: REQUEST FOR PRIOR AUTHORIZATION Phone (559)228-5400 (800) 652-2900 Please check Health PlanMRI, MRA, CT & Pet ScansM2A Video Capsule EndoscopyColonoscopy; Upper GI Endoscopy FAX (559) 224-2405 SERVICES REQUIRING PRIOR AUTHORIZATION (please check requested service)Obesity - Referral to General SurgeonObesity SurgeryOut-of- plan ProviderDME RentalDME Purchase over $200 Sleep StudiesSignature of Requesting PhysicianPlastic Surgery ReferralHome Health Home SurgeryEndocrinologist Visit (Type II Diabetes)(See reverse side of this form for more information)Infusions - Ambulatory (See reverse side of this form)Injections: Self-injectabl
O Aetna O Cigna O Secure Horizons O Aetna Golden Medicare Plan O Health Net ... REQUEST FOR PRIOR AUTHORIZATION Phone (559)228-5400 ...
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