blueshieldca.com/promise
Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association L52000-W-PHP (1/20)
601 Potrero Grande Drive | Monterey Park, CA 91755
TBSP11066 5/20
Durable Medical Equipment Treatment Authorization Request
Routine
Request
Modification/
Extension
Retroactive
Request
Urgent
Request
FAX: (323)889-6504
FAX (323)889-6504
FAX: (323) 889-5403
Important: Scheduling issues do not meet the definition of an urgent request. The definition of an urgent request is an
imminent and serious threat to the health of the enrollee; including but not limited to, severe pain, potential loss of
life, limb or major bodily function and a delay in decision-making might seriously jeopardize the life or health of the
enrollee.
Patient Information
Language spoken:
Member’s
name:
DOB: Gender: M F
Street
address:
City:
State:
ZIP code:
Members plan
ID number:
Effective
date:
Phone:
Service Information
Referral
requested by:
Request
date:
Referred to (servicing provider):
NPI/Tax ID:
Specialty:
Servicing provider's
full address:
Phone:
FAX:
Facility
name:
NPI/Tax ID:
Phone:
FAX:
Service(s) Requested:
CPT/HCPC code(s):
CPT/HCPC description:
ICD-10 code(s):
Dx description:
For modification/extension requests:
Date last authorized:
Previous Blue Shield Promise
authorization num
ber:
MD/NP/PA justification for request:
Requesting provider’s name (please print):
Provider’s signature:
Accident?
Yes No
If yes, where did he accident occur?
Home Work Auto Other:
IPA responsibility?
Check box, if yes
IPA authorization number:
Dates of service authorized (from/to):
PLEASE ATTACH THE LATEST AVAILABLE MEDICAL RECORDS AND PROGRESS NOTES. THIS REFERRAL DOES NOT GUARANTEE ELIGIBILITY. PLEASE CHECK
ELIGIBILITY BEFORE RENDERING SERVICE. Payment will not be made for unauthorized services. All lab and x-rays must be ordered/performed by
contracted providers. If you are unsure whether the provider is contracted with Blue Shield of California Promise Health Plan, contact Blue Shield
Promise’s Utilization Management Department at (800) 468-9935. Specialist findings must be sent to the member’s primary care physician.
Phone:
FAX:
-
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signature
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