HUMANA Pain Management Prior Authorization …

1 HUMANA pain ManagementPrior Authorization Request Form** Please complete and Fax this request form along with all supporting clinical documentation to OrthoNet at 1-888-605-5345. NOTE: The information transmitted is intended only for the person or entity to which it is addressed and may contain CONFIDENTIAL material. If you receive this material/information in error, please contact the sender and delete or destroy the For Internal Office Use OnlyRev. 4/1/2014 Copyright 2014 OrthoNet, LLCPATIENT INFORMATION: HUMANA Member ID NumberMonthDayYearDate of Birth//Last NameFirst Name(Must be completed in order to process request)3.

2 Please provide exact Epidural Levels or Facet Joint Levels or exact Medial Branch Nerves to be injected RightLeftBilateralEpidural Steroid Injection Facet Joint Injection2. Requested Procedure(s):TrialImplantSpinal Cord Stimulator:Trial (Narcotic - Baclofen - Prialt)Implant (Narcotic - Baclofen - Prialt) pain Pump:Facet Medial Branch Nerve Block:LocalSteroidRFA1. Primary Diagnosis CodeCervicalThoracicLumbarSacralPlease Select Spinal Region(s) which applies: If yes, ____% pain Relief lasted ____ weeks from last (Epidural or Facet injection) performed on Date:_____YesNo4. Previous Epidural or Facet Injections(s)?

3 CPT Code(s):Anticipated Date of Service(s)//MonthDayYearRequested Facility for Surgery/Procedure(s)(If Applicable)StateCityFacility Tax ID NumberPROVIDER INFORMATION:Fax Date://(including this cover page)Number of pages faxed :Street AddressProvider NameCityStateZIPF acility NPI NumberIndividual NPI NumberNational Provider Identifier (NPI)Facility Tax ID NumberIndividual Tax ID NumberProvider Tax ID NumberFax Number()-Telephone Number()-2100621006