UNITS:

Name of Referring Doctor

ICD-10:

UNITS:

This block contains code to alter the form appearance This block will not be visible on the live site.

DO NOT DELETE

UNITS:

Health Insurance Policy and Info, ICD:

Student Registration / Enrollment - Fall Semester: Enrollment starts on December 10th, 2025 and ends on January 15th, 2026

UNITS:

Providing Facility/Doctor/Vendor Name:

End Date:

Exceeding Your Expectations

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

Request's Contact Information: *

UNITS:

Start Date:

Procedure Code:

Providing Facility/Doctor/Vendor NPI:

UNITS:

Student First Name *

ICD-10:

DEAR STUDENT:PLEASE ENSURE YOU HAVE REGISTERED IN PERSON AT YOUR AT THE BOARD OF EDUCATION IN YOUR CITY OR TOWN TO OBTAIN YOUR REQUIRED EXAM ID NUMBER BEFORE TEMPTING TO COMPLEATE THIS ONLINE FORM. FAILURE TO DO SO WILL RESULT IN MAJOR DELAYS OF YOUR APPLICATION.

Start Date:

Name of Contact at Provider's Office/Facility:

Misc: Providing Hospital/Doctor Info.

Procedure Code:

Email *

Providing Facility/Doctor/Vendor Name:

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

Contact Info:

End Date:

Requesting Doctor's NPI #:

This is my ____ Request:

ICD-10:

Insured Person's Last Name:

ICD-10:

Provider's Office Contact Information

Start Date:

End Date:

Start Date:

Service Type:

Name of Contact at Provider's Office/Facility:

Name of Person Requesting this Authorization: *

End Date:

Start Date:

Information About Health Services Requested

Student High School Exam Registration ID# *

End Date:

Procedure Code:

Student / Insurance Information

Group ID # (if applicable):

Graduate Student Exam ID #: *

Dates of Service, Diagnosis, and Procedure Codes

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

Exam Type: *

New Student's Information

Patient DOB:

Providing Facility/Doctor/Vendor NPI:

Today's Date:

Procedure Code:

Student Health Insurance Name:

Student DOB: *

Auth. Context:

Student Last Name: *