Podiatric Services
Prior Authorization Request Form
Copyright 2021 OrthoNet, LLC
Rev. 3/23/2021
A S P
For Internal Office Use Onl
Fax Date:
/ /
includin
this cover
a
e
Number of pages faxed :
Last NameFirst Name
Month Da
Year
Date of Birth
/ /
Provider Name
Street Address
City State ZIP
Medicaid Member ID NumberHealthfirst Member ID Number
O
P
A
T
I
E
N
T
P
R
O
V
I
D
E
R
Healthfirst Provider ID National Provider Identifier (NPI) Provider Tax ID Number
Instructions: 1. Use this form as the fax cover sheet when requesting Podiatric prior authorization for Healthfirst members.
2. Please complete and Fax this request form along with all supporting clinical documentation to OrthoNet at 1-844-478-8250.
3. For assistance in completing this form, please contact OrthoNet toll free at 1-844-504-8091.
4. Please PRINT, in black ink, one character per box for ALL requested information and completely fill in each circle for selection where applicable.
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.
R
E
U
E
S
T
I
N
F
O
R
M
A
T
I
O
N
Ext
Fax Number
( ) -
Telephone Number
( ) -
Please attach to this fax clinical notes includin
the initial evaluation, all follow-u
notes dated within the last 3 months with
atient’s s
m
toms, exam findin
s, all
rior conservative mana
ement, documentation of sur
ical
lan and related
ima
in
re
orts dated within the last 12 months.
Setting:
Inpatient
Outpatient
Office
Anticipated Date of Service
/ /
Month Day Year
Requested Facility for Surgery/Procedure(s)
(If Applicable)
City State Facility Tax ID Number
(ICD-10)
Diagnosis Code
Laterality:
Right
Left
Bilateral
CPT Code:
Qty QtyCPT Code:
CPT Code:
Qty
Qty
CPT Code:
CPT Code: Qty
Qty
CPT Code:
Qty
CPT Code:
Qty
CPT Code:
49648
49648
