-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
Durable Medical Equipment Form
Diagnostics Report
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