TAR Attachment Form
1 SUBMITTING PROVIDER #
2 PATIENT RECORD #
3 PROVIDER PHONE # 4 PROVIDER FAX #
5 PROVIDER NAME
6 PROVIDER STREET/MAILING ADDRESS
11 PROVIDER CONTACT NAME
7 CITY
8 STATE 9 ZIP CODE
12 PROVIDER CONTACT PHONE #
13 ORIGINAL TAR
NUMBER
14 UPDATE RSN
15 SPCL HNDLG
16 RETRO RSN
17 RETRO DATE
31 MEDI-CAL IDENTIFICATION
NUMBER
32 PATIENT NAME, LAST
33 FIRST
34 SEX
35 RES
STAT
36 WRC
DATE
SIGNATURE OF PHYSICIAN OR PROVIDER
X
v5 9/22/06
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TREATMENT AUTHORIZATION REQUEST - ATTACHMENT FORM
STATE OF CALIFORNIA DEPARTMENT OF HEALTH SERVICES
INTERNAL CONTROL NUMBER - FI USE ONLY
3
CONFIDENTIAL PATIENT INFORMATION
PLEASE TYPE INFORMATION
PART I: PROVIDER INFORMATION
10 MEDICARE CERTIFIED
PART II: PATIENT INFORMATION
TO THE BEST OF MY KNOWLEDGE, THE ABOVE IS TRUE, ACCURATE, AND COMPLETE AND THE REQUESTED
SERVICES ARE MEDICALLY INDICATED AND NECESSARY TO THE HEALTH OF THE PATIENT.
Note: AUTHORIZATION DOES NOT GUARANTEE PAYMENT. PAYMENT IS
SUBJECT TO PATIENT'S ELIGIBILITY. BE SURE THE PATIENT'S ELIGIBILITY IS
CURRENT BEFORE RENDERING SERVICE.
CONFIDENTIALITY NOTICE: This fax transmission is for the sole use of the intended recipient
and may contain confidential and privileged information. Any unauthorized review or use, including
disclosure or distribution is prohibited. If you are not the intended recipient, please
contact the sender and destroy all copies of the fax transmission.
