REQUEST FORM (TAR) - Partnership HealthPlan

(PLEASE TYPE)(PLEASE TYPE) DEFERREDMDYYMMDDYMMDDYYMMDYYFAX #(FOR PROVIDER USE)PATIENT'S AUTHORIZED REPRESENTATIVE (IF ANY)ENTER NAME AND ADDRESS:DATEBY: APPROVED AS MODIFIED APPROVED AS REQUESTEDNAME AND ADDRESS OF PATIENTPATIENT NAME (LAST, FIRST, )FOR PHC USE ONLYDENIEDPROVIDER: YOUR REQUEST IS:COMMENTS / EXPLANATIONPHC CONSULTANT'S NAMEREVIEW COMMENT INDICATORY6 OFFICESEQUENCE NUMBERNOTE: AUTHORIZATION DOES NOT GUARANTEE PAYMENT. PAYMENT IS SUBJECT TO PATIENT'S ELIGIBLITY. BE SURE THE IDENTIFICATION CARD IS CURRENT BEFORE RENDERING OF PHYSICIAN OR PROVIDERNAME/ TITLETO DATECHARGESAUTHORIZATION IS VALID FOR SERVICES PROVIDEDDFROM DATETAR CONTROL NUMBERDATETO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS TRUE, ACCURATE AND COMPLETE AND THE REQUESTED SERVICES ARE MEDICALLY INDICATED AND NECESSARY TO THE HEALTH OF THE UNITSYESNDC / UPC OR PROCEDURE CODEUNITS OF SERVICESPECIFIC SERVICES REQUESTEDBOARD & CARE ACUTE HOSPITALMEDICAL JUSTIFICATION:PHONE NUMBER AREAHOMESNF/ICFSTREET ADDRESSMDATE OF BIRTHAGEDSEXCITY, STATE, ZIP CODEPROVIDER NAME AND ADDRESSDIAGNOSIS DESCRIPTION:CURRENT ICD-CM CODEPATIENT IDENTIFICATION IS RETROACTIVE ?

date to the best of my knowledge, the above information is true, accurate and complete and the requested services are medically indicated and necessary to …

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