Transcription of Website: NYS Medicaid Prior Authorization Request Form …
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Website: NYS Medicaid Prior Authorization Request Form …
Plan Name: NYS Medicaid Fee-For-Service Plan Phone No. (877) 309-9493 Plan Fax No. (800) 268-2990 Website: Information on this form is protected health information and subject to all privacy and security regulations under HIPAA. page 1 of 2 NYS Medicaid Prior Authorization Request Form For Prescriptions Rationale for Exception Request or Prior Authorization All information must be complete and legible Patient Information 1. First Name: 2. Last Name: 3. MI: Male Female 4. Date of Birth: 5. 6. ____/____/_____ Member ID: Is patient transitioning from a facility?
maintained by the American Medical Association (AMA). The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians and other health care professionals.
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