Fillable Authorization Request Form Toll Free 1.844.522.5282 TDD Relay

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Authorization Request Form Toll Free 1.844.522.5282 TDD Relay

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Authorization Request Form
Toll Free 1.844.522.5282
TDD Relay 1.800.955.8771 / Fax 1.855.328.0059
myHFHP.org
Forms without complete information or attached documentation WILL NOT be processed.
MUST COMPLETE
DATE OF REQUEST____________
CONTACT Name________________________________________________ Phone (_____)____________ Ext.______ Fax (_____)____________
MEMBER ID#____________________ First/Last______________________________________________________________ DOB____________
REQUESTING PROVIDER First/Last________________________________________________________________________________________
£ Check if requested by PCP / Phone (_____)____________ Fax (_____)____________
Check the applicable request types(s) below AND complete the requested information.
COMPLETE APPLICABLE INFORMATION FIELDS
OUT OF NETWORK (OON) SPECIALIST REFERRALS
£ Consult Only £ Consult w Diagnostics £ Consult/Diagnostics/Treatment £ 2ND OPINION
£ Initial Request £ Add Visit(s) / # of Ofce visit(s)_______ / Service date(s) from____________ to ____________
PERFORMING PROVIDER First/Last__________________________________________________ Specialty_____________________________
NPI #____________________ / TAX ID #______________________
Address_________________________________________________________________ Phone (_____)____________ Fax (_____)____________
==========================================================================================
TYPE OF SERVICE £ Ofce £ Outpatient £ Observation £ Ambulatory Surgery £ Inpatient £ SNF £ PT/OT/ST*
£ Other (See below for DMEPOS)______________________________________ Comment__________________________________________
PERFORMING/ADMITTING PROVIDER First/Last_______________________________________________ Specialty_____________________
Address (OON only)_______________________________________________________ Phone (_____)____________ Fax (_____)____________
FACILITY____________________________________________________________________________________________________________
Address (OON only)_______________________________________________________ Phone (_____)____________ Fax (_____)____________
* PT/OT/ST initial evaluation & progress notes must accompany request for additional visits
==========================================================================================
DME/PROSTHETICS/ORTHOTIC SUPPLIES (DMEPOS)
SUPPLIER NAME________________________________________________ Equipment______________________________________________
HCPCS Code(s) __________ __________ __________ __________ ___________ __________ __________ __________
£ Bilateral £ Right £ Left / £ Purchase OR £ Rental: £ 1st Month Rental £ 2nd or 3rd Month Rental £ 4-15 Month Rental
==========================================================================================
DIAGNOSIS Description____________________________________________________ Code(s) (ICD-CM)____________________________
PROCEDURE Description____________________________________________________ CPT/HCPCS Code(s)__________________________
SERVICE DATE(s) FROM ____________ TO ____________ # OF SERVICE(s)/UNIT(s)/VISIT(s)__________________________________
INPATIENT ADMISSION DATE ____________ EXPECTED DISCHARGE DATE ____________
==========================================================================================
HIP OR KNEE ARTHOPLASTY Has the patient completed a HFHP Joint Class? £ Yes £ No / £ Bilateral £ Right £ Left
Joint Class completed date ____________ Location of Joint Class_____________________________________________________________
REQUEST FOR EXPEDITED REVIEW (72 hours or less)
Criteria for expedited review: Waiting for a decision in the standard timeframe (14 days or less) could seriously harm the
member’s life, health, or ability to regain maximum function. I attest that this represents an expedited authorization as
dened above. Physician Signature:_______________________________________________________________
AUTHORIZATION DOES NOT GUARANTEE COVERAGE AND DOES NOT SUPERSEDE ANY MEMBER BENEFIT LIMITS
(INCLUDING DMEPOS COVERAGE LIMITS) OR PROVIDER CONTRACTUAL LIMITS.
CONFIDENTIALITY: The information contained in this facsimile message may be legally privileged and condential information intended only for the use of the
individual or entity named above. If the reader of this message is not the intended recipient, you are hereby notied that any dissemination, distribution or copying of
this telecopy is strictly prohibited. If you have received this telecopy in error, please immediately notify the sender above and return the original message to us at the
address above by the United States Postal Service. Thank you for your cooperation.
AFFIRMATIVE STATEMENT: UM decision making is based only on appropriateness of care and service and existence of coverage. Health First Health Plans & Insurance
does not reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for UM decision-makers do not encourage decisions
that result in under-utilization. REVISED: July 2015
£ Please process this request ASAP due to the Date of Service/Scheduling Constraints
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Authorization Request Form Toll Free 1.844.522.5282 TDD Relay

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Completed 13 September 2021

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