Phone- 850-877-0101 | Fax 850-877-2750 | www.tallyent.com. Appointment Request. Please note if your patient needs to be
(850) 877-8174 | Fax (850) 877-5636 (850) 877-8174 | Fax (850) 877-5636 ... Please advise patient that any copay/co-insu
Please call Bright Start or fax an updated form if the member has any changes in condition during pregnancy. This update
Please complete and fax this form to Caremark at 888-836-0730 to request a
Drug Specific Prior ... fax the Drug Specific Prior Authorization Request Form to
us, we will review it and notify you and ... Last Name, First Name (PLEASE PRINT
).
Office (850) 942-2299 | Fax (850) 942-0322. OUTPATIENT CONSULTATION FORM. Date of request: Patient's Name: DOB: Address:
MCINTOSH CLINIC, P.C.. 119 WEST HILL STREET. THOMASVILLE, GA 31792. (229) 225-1900 or (800) 782-8507. Rheumatology Dept.
MCINTOSH CLINIC, P.C.. 119 WEST HILL STREET. THOMASVILLE, GA 31792. (229) 225-1900 or (800) 782-8507. Rheumatology Dept.
management rules. WellCare will ... Information on this form is protected health information and subject to all privacy
Please Note: Medical Necessity Prior Authorization may be utilized to ... First
Name ... Dialysis:______ Long Term Care Facility:______ Self Injecting:______.
Return Merchandise Authorization (RMA) Request Form. Please fill out this form
completely. Pantone Customer Service will contact you to provide the RMA.
Request for Authorization Fax Form - Providers ... - HIE Networks
May 1, 2014 - For assistance please contact Utilization Management a 1-855-371-8074. Providers are responsible to obtain
Request for Authorization
To submit requests, please fax completed form to 1-855-236-9285 For assistance please contact Utilization Management a 1-855-371-8074
HEALTH CHOICE ®
Providers are responsible to obtain prior authorization for services prior to scheduling. Please submit clinical information as needed to support medical necessity of the request. Requests will not be processed if any of the following information is missing clinical information, specialist and/or primary care clinical summaries, or CPT and ICD-9 codes. As a reminder, authorization is not a guarantee of payment; payment is subject to benefit coverage rules, including member eligibility and any contractual limitations in effect at the time of service. Initial requests should be submitted via our website or fax. Today’s Date: Standard Request Expedited
Requested Date of Service: Prestige Health Choice has 7 days to render a decision from date of request, and can extend time frame by an additional 7 days. Prestige Health Choice, I certify that applying the standard review time frame may seriously jeopardize the life or health of the member. Prestige has 48 hours to render decision, and can extend time frame by an additional 2 business days.
Physician’s Signature:
Date signed:
A. Member Information Medicaid ID number:
Member Last Name:
Date of Birth:
Gender
Member First Name:
Male
Female
B. Review Type
Initial
*Change DOS/Setting
Cancel *Other (specify)
*Extension of Services
Additional Clinical
Discharge Planning (Services needed for member discharged from inpatient setting such as hospital, skilled nursing facility, etc.)
*Please Specify (If applicable, previous authorization number): Service Type:
DME
HomeCare
Orthotics/Prosthetic
Non-Par
Ob/Gyn
*Other
C. Provider Information Submitting Provider Name:
Contact Name
Contact Phone Number
Contact Fax Number
Services Provided By or Facility/Provider ID #:
DO NOT write below this line: Fields to be completed by Prestige Health Choice (Effective May 1, 2014) Authorization #
Prestige UM Agent Name: Page 1 of 3
P2045_1405
Member ID number: Treatment Setting
Outpatient
Inpatient
Home
In-Office
*Other
*Please specify if other selected:
D. HCPCS/CPT CODES ICD -9 Code HCPCS/CPT Code Description
Dates Of Service Through
From /
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Other Clinical Information: Include/attach clinical/office notes, labs, imaging reports to support medical necessity. If this is an out-of-network request, please provide an explanation.
E. Rehabilitation Services Type of Therapy:
Speech
Physical
Occupational
*Other
*Please specify if other selected: Number of Units/Visits Requested:
Extension
Previous Authorization Number:
Date(s) Requested :
Initial
DO NOT write below this line: Fields to be completed by Prestige Health Choice (Effective May 1, 2014) Authorization #
Prestige UM Agent Name: Page 2 of 3
P2045_1405
Member ID number:
F. Home Care
(Please first contact Univita Health for Home Care requests at 800-369-1416)
Name of Agency:
Number of Units/Visits Requested:
Date(s) Requested:
Previous Authorization Number: Extension
Initial
Additional Comments:
G. DURABLE MEDICAL EQUIPMENT
(Please first contact Univita Health for DME requests at 800-369-1416)
Diagnostic Indication:
Duration and Frequency of Use:
Acute or Chronic condition:
Previous Authorization Number:
Previous Authorization Number:
Length of time needed:
Initial
Renewal
Rental
Purchase
Additional Comments:
DO NOT write below this line: Fields to be completed by Prestige Health Choice (Effective May 1, 2014) Authorization #
