SECONDARY AUTHORIZATION REQUEST (SAR) …
secondary authorization request (sar) form fax to 1-866 -259 0311. section i: patient information last name: first name:
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Department of Veterans Affairs (VA) Patient …
www.triwest.comDepartment of Veterans Affairs (VA) Patient Centered Community Care (PC3) Confidential and Proprietary 1 Secondary Authorization Request Process Quick Reference Guide – PC3
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www.triwest.comFIELD 4 – Insured’s Name As in Field 2, please enter the patient’s name in the following order: the full last name, first name, and middle initial. Include the suffix (e.g., Jr, Sr.) after the last name and before the first name. Do not include any titles with the name. For an electronic claim, parts of a name go into separate fields.
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