Instructions:

Payment for services is dependent upon the patient's eligibility at the time services are rendered. Copays, coinsurance and/or deductibles may apply. Pre-certifications are valid for the date range specified on this form.


Please fill out all fields with *

Request Type

Please select your type of request from the dropdown.

Authorization Processing Time

Patient Information

Eligibility Verified?*

Future date is not available
Please match the requested format.
Please fill out this field.

Requesting Provider Information

Date of service TBD

Procedure Type?*

Servicing Provider Information

Provider Type?

Facility Information

Address same as servicing provider

Diagnosis CodeDiagnosis

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Procedure CodeProcedure or EquipmentUnitsFrequency

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Attachments

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Please submit all supporting clinical documentation with request.

*Max file size is 10MB.

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HIPAA Notice: The information contained in this form may be confidential and legally privileged information. It is only for the use of individual or entity named above. If the recipient of this form is not the recipient addressed on the form, you are hereby notified that any dissemination, distribution or copying of the attached document(s) is strictly prohibited. If you have received this in error, please immediately notify the sender by telephone and return the form to the sender.

Org. 11/17 Rev.



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