ICP Prior Authorization Form

Instructions:

Please validate patient eligibility and benefits prior to rendering services
Submit all clinical documentation such as progress notes/labs/radiology with requests
For questions, please call the Medical Management Department at (800) 250-6647 or (480) 400-0027

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.

This authorization request is approved based on Medical Necessity only and is not a guarantee of payment

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Please fill out all fields with *

Request Type

Please select your type of request from the dropdown.

Authorization Processing Time

Routine/Standard Request:Urgent Request:

Patient Information

Eligibility Verified?*

YesNo

Future date is not available

Please match the requested format.

Please fill out this field.

Requesting Provider Information

Date of service TBD

Procedure Type?*

InpatientOutpatient

Servicing Provider Information

Provider Type?

PhysicianPracticeFacilityVendor

In NetworkOut of Network

Facility Information

Address same as servicing provider

In NetworkOut of Network

Diagnosis Code	Diagnosis

Please fill out primary field.

Procedure Code	Procedure or Equipment	Units	Frequency

Please fill out primary field.

Available special characters are . , - / and space.

Attachments

*Attachment(s) is required

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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