___________________________________________________________________ ________________ ________________
_____________________________________________ _____________________________ _______________ ________________
__________________________________ ________________________________________________________
________________ ________________
______________________________________
______________ ______________
____________________________________
________________
__________________
______________
________________
_____________________________________
_______________________________
_________________________________________________
_________________________________________
__________________________________
____________________________________ ___________________________________
__________________________________________
P.O. BOX 11033 ORANGE, CA 92856 Phone: (714) 246-8686
AUTHORIZATION REQUEST FORM (ARF)
ROUTINE Fax to (714) 246-8579 RETRO Fax to (714) 246-8579
*** IN ORDER TO PROCESS YOUR REQUEST, ARF MUST BE COMPLET
ED AND LEGIBLE ***
PROVIDER: Authorization does not guarantee payment, ELIGIBILITY must be verified at the time services are
rendered
.
Patient Name:
Last First
M F D.O.B. Age:
Mailing Address: City: ZIP: Phone:
Client Index # (CIN): Name of ICF/SNF (if applicable):
Referring Provider:
Provider NPI#: TIN#:
Medi-Cal ID#:
Address: Phone:
Fax:
Office Contact:
Physician’s Signature:
Diagnosis:
Provider Rendering Service (Physician, Facility, Vendor):
Provider NPI#: __TIN#:
Medi-Cal ID#:
Address: Phone:
Fax:
Office Contact:
ICD-10:
AUTHORIZATION REQUEST
URGENT REQUEST Fax to (714) 338-3137. ***Definition: “Urgent” is ONLY when normal time frame for authorization will be
detrimental to patient’s life or health, jeopardize patient’s ability to regain maximum function, or result in loss of life, limb or other major bodily
function. Urgent requests are addressed within 72 hours.***
Inpatient Facility Outpatient Facility SNF Estimated Length of Stay:
Date(s) of Services: Retro Date(s) of Service:
List ALL procedures requested along with the appropriate CPT/HCPCS
REQUESTED PROCEDURES PERTINENT HISTORY (Submit supporting Medical Records) CODE (CPT or HCPCS) QUANTITY (REQUIRED)
DO NOT WRITE BELOW THIS LINE FOR CalOptima USE ONLY
STATUS
Approved Alternative Treatment
Not a Covered Benefit Modified
Not Medically Indicated Affiliated Health Plan:
Authorization Number #:
Signature: Date:
Comments:
Phone:
Revised 6/12/14
click to sign
signature
click to edit
![]()
