Transcription of Speech Therapy Prior Authorization Request Form 11962 ...
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Speech Therapy Prior Authorization Request Form 11962 ...
Speech Therapy Prior Authorization Request Form 11962 . Please fax to OrthoNet at: 1-844-888-2823. Fax Date: _____# of Pages Faxed: _____. Therapy PROVIDER INFORMATION. Facility or Provider Name Street Address City State ZIP. Telephone Number Fax Number ( ) - ( ) - The above fax number will be used to confirm your address/location if we are unable to contact you using the fax number on file with Healthfirst Healthfirst Provider ID National Provider Identifier (NPI) Provider Tax ID Number Facility NPI Number Individual NPI Number Facility TIN Number Individual TIN Number PATIENT INFORMATION: First Name Last Name Date of Birth / /. Month Day Year Healthfirst Member ID Number Medicaid Member ID Number OR. Request INFORMATION: Is this Request for post-operative Therapy visits? Request for: Yes No Onset (Commencement) of Therapy Services Initial Evaluation Date Extension of Therapy Services Other Procedure: _____ / /.
Initial Evaluation Date / / Month Day Year REQUEST INFORMATION: Request for: Onset (Commencement) of Therapy Services Extension of Therapy Services
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