Fillable Medical Prior Authorization Request (Sanford Health Plan)

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Medical Prior Authorization Request (Sanford Health Plan)

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The Medical Prior Authorization Request (Sanford Health Plan) form is 1 page long and contains:

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  • 10 check-boxes
  • 35 other fields

Country of origin: US
File type: PDF

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HP
-1295 09/20
Medical Prior Authorization Request
Patient Information
Member Name: Member ID#:
Address: City, State, Zip Code:
DOB: Phone Number:
Provider/Vendor Information
CPT Codes/HCPC Codes:
Inpatient: □
Outpatient □
Date of Service: Retro: □ Yes □ No
Primary Diagnosis – ICD-10: Secondary Diagnosis – ICD-10:
Ordering Provider
Referred To Provider/Facility
Ordering Provider Name: ___________________________
Specialty: _______________________
□ No specialty
Referred to Provider Name/Facility: ____________________
Specialty: _______________________
□ No specialty
Tax ID number: Tax ID number:
NPI number: NPI number:
Address: Address:
City, State, Zip Code: City, State, Zip Code:
Contact person at referring provider’s office: Contact person at referred to provider’s office:
Phone Number: Fax Number: Phone Number:
Clinical Information Submitted for Determination
Determination will be based on individual plan policy and clinical documentation submitted. Include all pertinent clinical documentation
to support the request. Check all that apply.
□ Letter of Medical Necessity
□ Diagnostic CDs
□ Current Clinical Notes
□ Colored Photos
□ Labs
□ Durable Medical Equipment Form
□ Diagnostics Report
□ Other
Signature
Codes not requested at time of service may result in a denied claim.
Requesting Person/Authorized Representative Signature:
Date Submitted:
Please complete, sign and date this form. Effective 10/1/20 we will be requesting that prior authorization requests be sent via our portal on
sanfordhealthplan.com. For instructions on how to request this access to the portal, please email providerrelations@sanfordhealth.org.
PO Box 91110
Sioux Falls, SD 57109
(605) 328-6868
Fax: (605) 328-6813
sanfordhealthplan.com
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Medical Prior Authorization Request (Sanford Health Plan)

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Completed 20 May 2021

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