Name of Contact at Provider's Office/Facility:

Providing Facility/Doctor/Vendor Information

Procedure Code:

Providing Facility/Doctor/Vendor Name:

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

Procedure Code:

Contact Info:

End Date:

Name of Person Requesting this Authorization: *

End Date:

Start Date:

Information About Services Requested

Procedure Code:

Insured Information

Group ID #:

Patient ID #:

Authorization Request Type:

Patient Information

Patient DOB:

Providing Facility/Doctor/Vendor NPI:

End Date:

Today's Date:

Procedure Code:

Insured's Employer Name:

Insured's DOB:

Auth. Context:

Patient Last Name: *

UNITS:

Patient First Name: *

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:

End Date:

Service Type:

Name of Contact at Provider's Office/Facility:

Start Date:

Insured Person's Member ID #:

End Date:

Dates of Service, Diagnosis, and Procedure Codes

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

ICD-10:

UNITS:

Insured's First Name

Procedure Code:

Requesting Doctor's NPI #:

Provider's Office Contact Information

UNITS:

Name of Referring Doctor:

UNITS:

Providing Facility/Doctor/Vendor Name:

UNITS:

Start Date:

ICD-10:

ePrecert

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

Providing Facility/Doctor/Vendor NPI:

Start Date:

Exceeding Your Expectations

Start Date:

ICD-10:

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UNITS:

End Date:

Request's Contact Information: *

This is my ____ Request:

Insured Person's Last Name: