PRIOR AUTHORIZATION REQUEST FORM - alliantplans.com

1 PRIOR AUTHORIZATION REQUEST form . Providers have access to submit PRIOR authorizations online. To register, visit DATE OF REQUEST : MM/DD/YYYY. SCHEDULED DATE OF SERVICE: MM/DD/YYYY. PROVIDER INFORMATION. Referring Physician Name: form Completed By: Phone Number: Fax Number: Patient Name: Member ID Number: ICD-10 code or Diagnosis: CPT: SERVICE INFORMATION. Provider Name: Type of Service (Please Select): Observation Inpatient Outpatient Ancillary PT OT ST Home Health Hospice DME HCPC(s):_____. Required for DME. CLINICAL INFORMATION. Please provide comments/clinical/supporting information to expedite the AUTHORIZATION : Physician Signature (Required): X. COMPLETED BY ALLIANT MEDICAL MANAGEMENT: AUTHORIZATION Number: Effective Date: Expires: Initial Inpatient LOS (if applicable): Amount of Outpatient services approved: Submit To Fax #: 866-370-5667 For Questions Call: 800-865-5922.

2 AHP - PRIOR AUTHORIZATION REQUEST form Rev. 8-30-16. Language Assistance Si usted, o alguien a quien usted est ayudando, tiene preguntas acerca de Alliant Health Plans, tiene derecho a obtener ayuda e informaci n en su idioma sin costo alguno. Para hablar con un int rprete, llame al (800) 811-4793. N u qu v , hay ng i m qu v ang gi p , c c u h i v Al liant Health Pl ans, qu v s c quy n c gi p v c th m th ng ti n b ng ng n ng . c a m nh mi n ph . n i chuy n v i m t th ng d ch vi n, xi n g i (800) 811-4793. Al l iant Health Pl ans .. (800) 811-4793 . [ SBM Al liant Health Pl ans ] . [ (800) 811-4793 .. , (800) 811-4793. Si vous , ou quelqu'un que vous tes en tra in d'aider, a des questions propos de Alliant Health Plans, vous a vez le droit d'obtenir de l 'aide et l 'i nformation dans votre langue aucun co t.]

3 Pour parler un i nterpr te, appelez (800) 811-4793. Alliant Health Pl ans . (800) 811-4793 . , Alliant Health Plans , . , (800) 811-4793 . Si oumenm oswa yon moun w a p ede gen kesyon kons nan Alliant Health Plans, se dwa w pou resevwa asistans a k enf masyon nan lang ou pale a , s a n ou pa gen pou peye pou sa. Pou pale av k yon ent pr t, rele nan (800) 811-4793. Если у ва с или лица , которому вы помогаете, имеются вопросы по поводу Al liant Health Plans, то вы имеете право на беспла тное получение помощи и информа ции на ва шем языке. Для разговора с переводчиком позвоните по телефону (800) 811-4793. Al l iant Health Plans .. ( 800) 811-4793. Se voc , ou a lgu m a quem voc est a judando, tem perguntas sobre o Alliant Health Pl ans, voc tem o direito de obter a juda e informa o em seu i di oma e s em custos.

4 Pa ra falar com um int rprete, ligue para (800) 811-4793. Al l iant Health Plans . ( 800) 811-4793.. Fa l ls Sie oder jemand, d em Sie helfen, Fragen zum Alliant Health Pl ans haben, h aben Sie das Recht, k ostenlose Hilfe und Informationen in Ihrer Spra che zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer (800) 811-4793 a n. Al l iant Health Pl ans . (800) 811-4793 . TTY/TDD. ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1-(800) 811-4793 (TTY/TDD: 1- (800) 811-4793). Non Discrimination Alliant Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Alliant Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

5 Alliant Health Plans cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Alliant Health Plans tu n th lu t d n quy n hi n h nh c a Li n bang v kh ng ph n bi t i x d a tr n ch ng t c, m u da, ngu n g c qu c gia, tu i, khuy t t t, ho c gi i t nh. Alliant Health Plans ( ) , , , , .. Alliant Health Plans . Alliant Health Plans , , , , .. Alliant Health Plans respecte les lois f d rales en vigueur relatives aux droits civiques et ne pratique aucune discrimination bas e sur la race, la couleur de peau, l'origine nationale, l' ge, le sexe ou un handicap. Alliant Health Plans .. Alliant Health Plans , , , , , .. Alliant Health Plans konf m ak lwa sou dwa sivil Federal ki aplikab yo e li pa f diskriminasyon sou baz ras, koul , peyi orijin, laj, enfimite oswa s ks.

6 Alliant Health Plans соблюдает применимое федеральное законодательство в области гражданских прав и не допускает дискриминации по признакам расы, цвета кожи, национальной принадлежности, возраста, инвалидности или пола. Alliant Health Plans . Alliant Health Plans cumpre as leis de direitos civis federais aplic veis e n o exerce discrimina o com base nara a, cor, nacionalidade, idade, defici ncia ou sexo. Alliant Health Plans .. Alliant Health Plans erf llt geltenden bundesstaatliche Menschenrechtsgesetze und lehnt jegliche Diskriminierung aufgrund von Rasse, Hautfarbe, Herkunft, Alter, Behinderung oder Geschlecht ab. Alliant Health Plans.