Prior Authorization Request (PAR) Coversheet

1 Expedited Request ? Initial Request Resubmission Request Note: Expedited requests require justification to meet expedited DateNumber of Pages (including Coversheet )For HCPCSE ntity Submitting Supplier Physician/Treating Practitioner (TP) Supplier NamePhysician/TP NameSupplier AddressPhysician/TP AddressSupplier PhonePhysician/TP PhoneSupplier Contact NamePhysician/TP FaxSupplier FaxPhysician/TP NPIS upplier NPIS upplier PTANB eneficiary NameMedicare NumberBeneficiary State of ResidenceBeneficiary Date of BirthFor additional information such as medical policy, please visit our websites for: Power Mobility Devices.

2 Group II Pressure Reducing Support Surfaces: Fax the PAR to: to: CGS JUR C DME Medical Review Condition of Payment ProgramPO Box 24890 Nashville, TN 37202-4890 JURISDICTION CCondition of Payment Prior Authorization (PA) ProgramRevised September 16, 2019. 2019 Copyright, CGS Administrators, LLC.