Fill - Free fillable Outpatient Authorization Request PDF form

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Outpatient Authorization Request

Instructions: Please address all 3 pages of this form in it’s entirety and save it to your desktop

prior to beginning. All elds in this form are required unless otherwise indicated (optional / applicable).

If you have questions about this request, call Blue Cross Blue Shield of North Dakota (BCBSND) Utilization

Management at 800-952-8462.

Please send the completed authorization request form with all supporting clinical documentation by:

• Fax: 701-277-2971

• Mail: BCBSND

4510 13th Ave S

Attn: Utilization Management

Fargo ND 58121

Initial Request Continued Care

Member Information

Patient First Name

Patient Last Name

Patient Date of Birth (MM/DD/YYYY) Member ID (including alpha-numeric prex)

Relationship to Subscriber:

Self Spouse Child Other

Provider Information

Requesting Provider First Name Requesting Provider Last Name Fax Number

Specialty/Taxonomy Code (Optional) NPI TIN (Optional)

Address Line 1 Address Line 2 (Optional)

City State Zip

Servicing Provider/Servicing Facility Information

Service Provider First and Last Name or Facility Name Phone Number

Fax Number NPI TIN (Optional)

Address Line 1 Address Line 2 (Optional)

City State Zip

Completed by Information

Completed by Name

Completed by Contact Phone Number Today’s Date (MM/DD/YYYY)

Contact for Additional Questions

Additional Contact Name Additional Contact Phone Number

Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association

Noridian Mutual Insurance Company

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Service Information

Service Type (Select One)

Applied Behavior Analysis Therapy Dental Accident Infertility Oral Surgery Private Duty Nursing

Anesthesia Partial Hospitalization (Psychiatric) Prosthetic Device Surgical Chemotherapy

Home Health Care Partial Hospitalization (Substance Abuse) Respite Care Transplants

Durable Medical Equipment Rental Durable Medical Equipment Purchase Medical Pharmacy

Diagnostic Lab Hospice Occupational Therapy Physical Medicine Speech Therapy rTMS

Place of Service (Select One)

Ambulance (Air or Water) Ambulance (Land) Ambulatory Surgical Center Hospice Oce

Home Independent Laboratory Partial Hospitalization

Request Type (Select One)

Initial (Complete Initial Service Information Section) Concurrent (Complete Concurrent Service Information Section)

Initial Service Information

Start of Care Date (MM/DD/YYYY)

To Date (If applicable)

Diagnosis Code(s) (ICD-10-CM ONLY, 1 required, up to 12 more if applicable)

Code (ICD-10-CM) Description

Code (ICD-10-CM)

Description

Code (ICD-10-CM) Description

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Initial Service Information

Procedure Code(s) (CPT/HCPCS, 1 Required, up to 14 more, if applicable)

Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units)

Concurrent Service Information

Start Care Date (MM/DD/YYYY) Previously Approved Services

CASE Number or REQ Number of Previous Request Start Date of Concurrent Care Request (MM/DD/YYYY)

Additional Diagnosis Code(s) since Initial Review (ICD-10-CM ONLY, If applicable)

Code (ICD-10-CM) Description

Procedure Code(s) (CPT/HCPCS, 1 Required, up to 5 more, if applicable)

Code (CPT/HCPCS) Description Quantity Requested Quantity Type (Days/Units)

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