Diagnosis Code
Street Address
Provider Name
City
State ZIP
YearDa
Month
Date of Birth
/ /
Provider Tax ID
* The above fax number will be used to confirm
our address/location if we are unable to
contact you usin
the fax number on file with the Health Plan.
Telephone Number
( ) -
Fax Number*
( ) -
A S P
For Internal Office Use Onl
MUSCULOSKELETAL SURGICAL PROVIDER INFORMATION
PATIENT INFORMATION
Last NameFirst Name
Instructions: 1. Use this form when requesting prior authorization of Musculoskeletal Surgery procedures for Humana Commercial and Medicare
Advantage members.
2. Please complete and Fax this request form along with all supporting clinical documentation to OrthoNet at 1-866-621-9008.
3. Please ensure that this form is a DIRECT COPY from the MASTER.
4. Please PRINT, in black ink, one character per box for ALL requested information and completely fill in each circle for selection where applicable.
5. For assistance in completing this form, please call OrthoNet provider services toll free at 1-866-565-4733.
NOTE:
The information transmitted is intended only for the person or entity to which it is addressed and may contain CONFIDENTIAL material.
If you receive this material/information in error, please contact the sender and delete or destroy the material/information.
SuffixHumana Member ID Number
Humana Musculoskeletal Surgical
Prior Authorization Request Form
Anticipated Date of Service(s)
/ /
Month Da
Year
Site:
Right
Left
Bilateral
Setting:
Inpatient
Outpatient
Observation
CPT Code(s):
Requested Facility for Surgery/Procedure(s)
City State
Facility Tax ID
Please include the current office notes
3 months
that
su
ort the
ro
osed
rocedure includin
an
radiolo
.
RE
UEST INFORMATION
Fax Date:________ #of Pa
es Faxed:____
ICD-10 Format
Street Address
in the
ast 6 months?
Has the patient had an MR/CT
Yes No N/A
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