End Date:

Exceeding Your Expectations

Insured's First Name

Additional Notes or Comments (any additional information to help us make a determination on this case):

Procedure Code:

Patient Information

Patient DOB:

Procedure Code:

Insured's Employer Name:

Auth. Context:

Patient Last Name: *

Dates of Service, Diagnosis, and Procedure Codes

(Enter all that apply - enter "None" in first line if none apply for that category):

Today's Date:

Insured's DOB:

ICD-10:

PROVIDERS/VENDORS: PLEASE FAX A COPY OF THE INSURANCE ID CARD AND CLINICAL INFORMATION FOR THIS CASE TO 765.447.8335 FAILURE TO FAX OVER INFORMATION REQUIRED WILL RESULT IN DELAY OR POTENTIAL CLOSURE OF REVIEW PROCESS.

Start Date:

Name of Contact at Provider's Office/Facility:

Contact Info:

End Date:

Name of Person Requesting this Authorization: *

End Date:

Insured Person's Member ID #:

End Date:

Patient ID #:

End Date:

Procedure Code:

ePrecert

UNITS:

Procedure Code:

Providing Facility/Doctor/Vendor NPI:

ICD-10:

Insured Person's Last Name:

Start Date:

Insured Information

Providing Facility/Doctor/Vendor NPI:

UNITS:

Name of Referring Doctor:

ICD-10:

UNITS:

Start Date:

Provider's Office Contact Information

Start Date:

Service Type:

Name of Contact at Provider's Office/Facility:

Start Date:

Procedure Code:

Authorization Request Type:

Providing Facility/Doctor/Vendor Information

Procedure Code:

ICD-10:

Information About Services Requested

Group ID #:

UNITS:

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UNITS:

Patient First Name: *

Requesting Doctor's NPI #:

This is my ____ Request:

End Date:

Start Date:

Providing Facility/Doctor/Vendor Name:

Request's Contact Information: *

ICD-10:

Providing Facility/Doctor/Vendor Name:

UNITS:

Brief Clinical Summary of Patient's Condition/Short Terms Goals (Psych):