*REQUIRED FIELDS Pre-Authorization Request Form

URGENCY OF Request : Standard 5 days Urgent 3 days Emergency 24 hours KERN LEGACY HEALTH PLANS Employee and Retiree Health Plan Options Pre-Authorization Request form 1115 Truxtun Ave, 1st Floor | Bakersfield CA 93301 | Ph: 661 868-3280 |UM Fax: 661 868-3291 | Kern Legacy Share Select | Kern Legacy Network Plus authorization form Revised December 7, 2018 Fax Request to *REQUIRED FIELDS Patient Information Last Name*: First Name*: Suffix: MI: Sex*: M F Member ID*: DOB*: PCP*: Other Health Coverage*: No Yes Street Address: City/State/Zip: Phone*: Subscriber Information (if the patient is a minor) Last Name: First Name: Relationship to Patient: Provider Information Requesting Physician*: NPI*: Phone*: Provider Signature*: Date*: Fax*: Mark the Kern Legacy Health Plan that your patient is enrolled in*: Type of Pre-Authorization Request : Kern Legacy Share Select Kern Legacy Network Plus Outpatient Inpatient There is NO Out-of-Netwo

URGENCY OF REQUEST: Standard – 5 days Urgent – 3 days Emergency – 24 hours KERN LEGACY HEALTH PLAN Employee and Retiree Health Plan Options Pre-Authorization Request Form 1115 Truxtun Ave, 1st Floor | Bakersfield CA 93301 | Ph: 661 868-3280 |UM Fax: 661 868-3291 | www.kernlegacyhp.com Kern Legacy Health Plan – Authorization Request Form

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