Please Do Not Copy
Prior Authorization Request Hospital Outpatient Procedures
Expedited Medicare Part A Fax/Mail Cover Sheet
*A prior authorization request is considered expedited only when the standard timeframe for making a prior
authorization decision could seriously jeopardize the life or health of the beneciary.
Complete all elds; attach supporting medical documentation and fax to 855- 815-3065 or mail to the applicable
address/number provided at the bottom of the page. Complete ONE (1)
Medicare Fax/ Mail Cover Sheet for each
prior authorization request for which documentation is being submitted.
Beneciary Last Name Beneciary First Name
q Male q Female
Facility/Agency NPIs CMS Certication Number
Facility Name and Address
Providers NPI Provider
s CMS Certication Number
s Name and Address
Requestor Name
Requestor Phone Number
Requestor Fax Number/Email address
Procedure Code(s)
Paired Code(s) for Botulinum Toxin Injections
Diagnosis Codes (providers who submit using esMD must include diagnosis code(s)):
Start Date of Authorization
State (location) of Authorization
Units of Service
Request Completed by:
(please print and sign)
This document is intended solely for the use of the individual or entity to which it is addressed and may contain
information that is privileged, condential, and exempt from disclosure under applicable law. If the reader of this notice
is not the intended recipient or individual responsible for delivering the message to the intended recipient, you are hereby
advised that any dissemination, distribution or copying of this information is strictly prohibited. If you receive this
communication in error, please advise us by telephone and destroy these papers.
P.O. Box 3033
Mechanicsburg, PA 17055
53719 (6-20)