Virginia Beach, VA 23462
757-552-7474 | 1-800-229-8822
Authorization status can be checked at optimahealth.com or by
calling Provider Relations at 1-800-229-8822
Commercial Plans: Authorization f
or
Future Inpatient and Outpatient Services
Inpatient Requests: FAX to 757-431-7760 or 1-844-668-1553
Outpatient Requests: FAX to 757-431-7761 or 1-844-723-2094
Member Name / Last, First
The below information and pertinent medical notes are required to process your request:
□ Out of Are a Re quest □ Inpatient Admission □ Outpatient Service □ 23 Hour OBS
Date of Service____/____/____
Diagnosis Codes: ____ _/____ ___/___ ____/_______
Diagnosis Description: ________________________________
Procedure Codes:
_______________/_________________/_________________/________________/___________________
Procedure Description:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Provider Information
Full Name of Ordering Physician:______________________________Specialty:________________________
Optima Provider # ________________NPI #________________________Tax ID #______________________
Full Name of Servicing Provider/Facility:_______________Phone:___________________Fax:_____________
Optima Provider #_________________NPI #________________________Tax ID #______________________
Person Completing Form:_____________________Phone:_____________________Fax:________________
