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Spinal Surgery Prior Authorization Request Form Telephone Number ( ) - Fax Number ( ) - Facility NPI Number Individual NPI Number National Provider Identifier (NPI) Facility Tax ID Number Individual Tax ID Number Provider Tax ID Number Facility or Provider Name Street Address City State ZIP Fax Date: / / (including this cover page) Number of pages faxed : PROVIDER INFORMATION: Month Day Year Date of Birth / / Last Name First Name PATIENT INFORMATION: A S P For Internal Office Use Only Anticipated Date of Service(s) / / Month Day Year / / Month Day Year If yes, what was the most recent date of surgery? REQUEST INFORMATION: Has the patient had prior spinal surgery? Yes No N/A the past 6 months? Has the patient had an MR/CT in Yes No N/A request? Is the MR/CT report attached to this Yes No N/A Requested Facility for Surgery/Procedure(s) (If Applicable) State City Facility Tax ID Number CPT Code(s): Please attach to this fax submission the current office notes (3 months) that support the proposed procedure. Setting: Inpatient Outpatient Observation Spinal Level(s): Spinal Region(s): Cervical Thoracic Lumbar Request for: Spinal Decompression Spinal Fusion Vertebroplasty/Kyphoplasty Other Diagnosis Code (ICD-10 Format) NOTE: The information transmitted is intended only for the person or entity to which it is addressed and may contain CONFIDENTIAL material. If you receive this material / information in error, please contact the sender and delete or destroy the material/information. Instructions: 1. Use this form when requesting prior authorization of Spinal Surgery procedures for members of EmblemHealth.

2. Please complete and Fax this request form along with all supporting clinical documentation to OrthoNet at 1-844-296-4440. (This completed form should be page 1 of the Fax.)
3. For assistance in completing this form, or if you should have any question about whether or not the procedure requires prior authorization, please contact OrthoNet toll free at 1-844-730-8503 for Spinal Surgery procedures.
4. Please PRINT, in black ink, one character per box for ALL requested information and completely fill in each circle for selection where applicable. Copyright 2015 OrthoNet LLC Health Plan Member ID Number 33049 33049