Fillable NHP AUTHORIZATION FORM

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NHP AUTHORIZATION FORM

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NHP AUTHORIZATION FORM
DMEnsion Benefit Management
Telephone: 1.866.205.2122
Fax: 1.248.844.3824
PROVIDER INFORMATION
*Contact Name
(“*” indicates required field) *Date
*Telephone Number *Fax#
*Provider Name *Provider City/State *NPI #
Is this an urgent request? Yes No If yes, please check reason: Hospital/SNF Discharge
PATIENT INFORMATION
Need within 24 hrs to avoid serious
harm/impairment/dysfunction/pain to member
*Last Name *First Name *DOB
*NHP ID # *Diagnosis (1) (2)
*Other Insurance Name * Primary to NHP: Yes No
*Service Date *HCPC Code *Description (For NOC Services include: Manuf., model # & cost) *Valid Dates *Amt. for NOC *Qty *RR/NU
Authorization Number CSR
***If your date of service changes, you must call (866) 205-2122 and have the date of service changed prior to claims submission. (revised 12/2015)
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NHP AUTHORIZATION FORM

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Completed 23 February 2022

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