Az Standard Prior Auth Form Healthcare Services.Pdf Form

Prior Authorization Request for Healthcare Services 1 – SUBMISSION INFORMATION Name Phone Fax Date

    /        /

4 – PATIENT INFORMATION Name Phone DOB Gender M
F Member Name (if different from above) Member ID # Group Name or Number 3 – EXPEDITED/URGENT REVIEW Expedited/Urgent Review Requested — By checking this box and signing below, I certify that applying the standard review time frame may seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function. Signature of Prescriber or Prescriber’s Designee /s/ 2 – REASON FOR REQUEST Review Type Clinical Reason for Urgency Non-Urgent
Urgent
Request Type Previous Authorization Number Initial
Extension/Renewal/Amendment (* = Required Field) Please check if applicable: I am a Gold Card Program provider and would like to use my Gold Card privileges via this form. Note: We will get back to you as soon as possible with your authorization number. To expedite, call 602-864-4811. I am seeking authorization for out-of-network care at the in-network level of benefits for the reason indicated below. Please complete the entire form. Requesting Provider Tax ID Servicing Provider Tax ID Optional Information Continuity of Care Geographic Barrier No Available In-Network Provider Other (describe below) Please enter tax IDs:

    /
    /
    /

5 – PROVIDER INFORMATION Requesting Provider or Facility Service Provider or Facility Provider/Facility Name Provider/Facility Name NPI # Specialty NPI # Specialty Phone Fax Phone Fax Contact Name Phone Service Care Provider’s Name Phone Fax Physical Therapy Occupational Therapy Speech Therapy Cardiac Rehab Mental Health/Substance Abuse Number of Sessions Duration Frequency Other Home Health Order Attached?
Yes
No Nursing Assessment Attached?
Yes
No Number of Visits Duration Frequency Other 7 – CLINICAL DOCUMENTATION (attach clinical documentation as needed) Comments/Notes 2308650-26 Blue Cross, Blue Shield, and the Cross and Shield Symbols are registered service marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Save and fax this form to AZ Blue at 1-844-263-2272. If you have questions, call us at 1-844-995-2583. 6 – SERVICES REQUESTED* (with CPT, CDT, or HCPCS code) and supporting diagnosis (with ICD code) Planned Service/Procedure (include number of units if applicable) Code Start Date End Date Diagnosis Description (include ICD version) Code

 /      /
 /      /
 /      /
 /      /
 /      /
 /      /
 /      /
 /      /

Inpatient Outpatient Provider Office Observation Home Day Surgery Other