Transcription of REQUEST FOR PRIOR AUTHORIZATION - Superior HealthPlan
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REQUEST FOR PRIOR AUTHORIZATION - Superior HealthPlan
REQUEST FOR PRIOR AUTHORIZATIONDate of REQUEST * First Name Last Name Member ID* Date of Birth*Member InformationLast Name, First Initial or Facility Name Contact Name / Requestor NPI* TPI* Ta x ID* Contact Number* Fax Number*Servicing Provider InformationContact InformationNPI* TPI* Ta x ID*Last Name, First Initial or Facility Name Contact Name / Requestor Contact Number* Fax Number*Referring Provider Information (eg. PCP or Specialist)Check box if same as ServiceOfficeOutpatient Hospital / ASC GenHomeOutpatient ClinicOutpatient RehabInpatientOtherPlace of Service*RehabOutpatient ServicesEvaluationsOffice VisitDME Rental*DME Purchase*DME Incontinence Supply*FOR OFFICE USE ONLYNon-Emergent TransportationInpatientRe-EvaluationsHom e HealthSNVPDNT herapyOther Type of Service*All DME require signed physician orders.
Authorization Number. Units Dates Authorized. Genetic Testing Type: Pregnant. Yes No. Urgent Request - By checking this box, I certify that this is an urgent request medically necessary treatment, which must be treated within 24 hours.
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