Transcription of 2. Please complete and Fax this request form along …
1 Podiatric ServicesPrior Authorization request FormInstructions: 1. Use this form when requesting prior authorization of Podiatric procedures for Healthfirst Please complete and Fax this request form along with all supporting clinical documentation to OrthoNet at 1-844-478-8250. ( this completed form should be page 1 of the Fax.)3. For assistance in completing this form , or if you should have any question about whether or not the procedure requires prior authorization, Please contact OrthoNet toll free at 1-844-504-8091 for Podiatric Please PRINT, in black ink, one character per box for ALL requested information and completely fill in each circle for selection where.
2 The information transmitted is intended only for the person or entity to which it is addressed and may contain CONFIDENTIAL you receive this material / information in error, Please contact the sender and delete or destroy the Date://(including this cover page)Number of pages faxed :PROVIDER INFORMATION:PATIENT INFORMATION:ASP For Internal Office Use OnlyCopyright 2015 OrthoNet, LLCRev. 6/1/2015 Requested Facility for Surgery/Procedure(s)(If Applicable)StateCityFacility Tax ID NumberLast NameFirst NameMonthDayYearDate of Birth//Arthroplasty/ExostectomyTenotomy/ CapsulotomyMedicaid Member ID NumberHealthfirst Member ID NumberORREQUEST INFORMATION:Diagnosis CodeDiagnosis Code(ICD-9 or ICD-10 Format)Diagnosis CodeRequest for:BunionectomyOstectomy/OsteotomyOther Procedure(s):_____Other Procedure(s): _____Please attach to this fax submission the current officenotes (3 months) that support the proposed procedure(s).
3 Anticipated Date of Service(s)//MonthDayYearHas the patient hadfoot surgery inthe past 6 months?YesNoN/AIf yes, Please provide the most recent dateof surgery://MonthDayYearHas the patient hadconservative treatmentin the past 6 months?YesNoN/ASetting:InpatientOutpatie ntCPT Code(s):Facility or Provider NameStreet AddressCityStateZIPFax Number()-Telephone Number()-Facility NPI NumberIndividual NPI NumberNational Provider Identifier (NPI)Healthfirst Provider IDProvider Tax ID NumberFacility TIN NumberIndividual TIN Number2933829338
