Phone (800) 874 -2091 DATE SUBMITTED: - Preferred Ipa of ...

1 Fax authorization request to: (800) 874-2093 Phone (800) 874 -2091 REFERRAL / AUTHORIZATION REQUEST Check one health plan below : Select membership type: Blue Cross Citizens Choice Care Medi-Cal Blue Shield Easy Choice Humana Healthy Kids Brand New Day Health Net Molina Medicare or Cal MediConnect Care 1st Covered California MARK HERE FOR TYPE OF REQUEST: URGENT ROUT INE RET ROA C T I V E INPA T IENT Patient Name LAST FIRST MA L E FEMA L E DOB A GE Address City Zip Phone Member Number Language Required (Interpreter Services Available) PATIENT REFERRED TO: Address: Specialty: Phone #: FAX #: REFERRING PHYSICIAN: Referring Physician Address Referring Phone : Referring Fax.

2 Referring Signature (REQUIRED) Diagnosis Codes (ICD9): Diagnosis Description: ICD9 Code 1: ICD9 Code 2: IMPO RTANT NO TIC E REGARDING Q UES T an d LAB C O RP - LABS MUST BE SENT T O T HE ASSIGNED CONT RACT ED LAB FOR T HE MEMBER S PCP. PLEASE CALL 818-265-0800 X200 T O VERIFY P CP S CONT RACT ED LABORAT ORY SERVICE P ROVIDER. CPT CODES CPT CODES Consultation w / Dx & Report Out-Patient Procedure Follow-up Visit (_____/visits) DME / Prosthetics Ultrasounds Home Health Care Routine Pregnancy Care LMP:_____ EDC: _____ CT/ MR I Family Planning Physical Therapy Visit Hospital In-Patient Care Other Reason for referral A T T A C H PERT INENT PROGR ESS NOT ES, C ONSUL T NOT ES, L A BORA T ORY/ X- RA Y RESUL T S What has been tried?

3 For how long? With w hat results? How w ill this af f ect treatment? Please explain. AUTHORIZATION OF REQUESTED SERVICES AND PAYM ENT OF CLAIM S ARE BASED ON VERIFICATION OF CONTINUED ELIGIBILITY. SPECIALIST: PLEASE PROVIDE CONSULTATION REPORT AND FOLLOW UP NOTES TO PCP **SPECIALISTS MAY REQUEST FOLLOW UP VISITS OR PROCEDURES DIRECTLY** Practitioners, members and the public may request a copy of the criteria used to make an authorization decision by calling the IPA. If you would lik e to discuss a denial decision, you may contact the Medical Director at 818-265-0800 x249.

4 Approved Pend Denied Modif ied Review Date_____ ____ ____ __ Medical Director Signature_____ ____ ____ ____ ____ ___ ____ ____ ____ ____ ____ __ Date_____ ____ __ Comment: date S UB MITT ED: _____ NOT ES A ND L A B/X-RA Y RESUL T S A RE REQUI R E D T O PROC ESS REQUES T 07/2014