Fillable Outpatient Treatment Authorization Request (Blue Shield of California)

Fill Online, Printable, Fillable, Blank Outpatient Treatment Authorization Request (Blue Shield of California) Form

Use Fill to complete blank online BLUE SHIELD OF CALIFORNIA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Outpatient Treatment Authorization Request (Blue Shield of California)

On average this form takes 19 minutes to complete

The Outpatient Treatment Authorization Request (Blue Shield of California) form is 3 pages long and contains:

  • 2 signatures
  • 13 check-boxes
  • 62 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Blue Shield of California forms online.

BROWSE BLUE SHIELD OF CALIFORNIA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
blueshieldca.com/promise
Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association L52000-W-PHP (1/20)
601 Potrero Grande Drive | Monterey Park, CA 91755
TBSP11068 (5/20)
Outpatient Treatment Authorization Request
Routine
Request
Modification/
Extension
Retroactive
Request
Urgent
Request
FAX: (323)889-6506
FAX (323)889-6506
FAX: (323) 889-5403
Important: Scheduling issues do not meet the definition of an urgent request. The definition of an urgent request is an
imminent and serious threat to the health of the enrollee; including but not limited to, severe pain, potential loss of
life, limb or major bodily function and a delay in decision-making might seriously jeopardize the life or health of the
enrollee.
Patient Information Language spoken:
Member’s
Name:
DOB: Gender: M F
Street
address:
City:
State:
ZIP Code:
Member’s plan
ID number:
Effective
date:
Phone:
Service Information
Referral
requested by:
Phone:
FAX:
Request date:
Referred to (servicing provider):
NPI/Tax ID:
Specialty:
Servicing provider's
full address:
Phone:
FAX:
Facility name:
NPI/Tax ID:
Phone:
FAX:
Service(s) Requested:
Initial
consult
Follow-up
visits
Outpatient
procedure(s)
Transportation
Other:
CPT/HCPC code(s):
CPT/HCPC
description:
ICD-10 code(s):
Dx
description:
For modification/extension requests:
Date last authorized:
Previous Blue Shield Promise
authorization number:
MD/NP/PA justification for request:
Requesting provider’s name (please print):
Provider’s signature:
Accident?
Yes
No
If yes, where did the accident occur?
Home Work Auto Other:
IPA responsibility?
Check box, if yes
IPA authorization number:
Dates of service
authorized (from/to):
PLEASE ATTACH THE LATEST AVAILABLE MEDICAL RECORDS AND PROGRESS NOTES. THIS REFERRAL DOES NOT GUARANTEE ELIGIBILITY. PLEASE CHECK
ELIGIBILITY BEFORE RENDERING SERVICE. Payment will not be made for unauthorized services. All lab and x-rays must be ordered/performed
by contracted providers. If you are unsure whether the provider is contracted with Blue Shield of California Promise Health Plan, contact Blue Shield
Promise’s Utilization Management Department at (800) 468-9935. Specialist findings must be sent to the member’s primary care physician.
-
click to sign
signature
click to edit
blueshieldca.com/promise
Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association L52000-W-PHP (1/20)
601 Potrero Grande Drive | Monterey Park, CA 91755
Medi-C
al and Cal MediConnect Physician’s Certification Statement
Request for Transportation
This form authorizes the provider of transportation to provide the appropriate level of
transportation needed by the Blue Shield of California Promise Health Plan Medi-Cal or Cal
MediConnect member.
Member’s name:
Member’s plan ID number:
Member’s date of birth (DOB):
Non-emergency medical transportation (NEMT)
Non-medical transportation (NMT)
NEMT includes ambulance, wheelchair and
gurney vans, and is provided when it is medically
necessary, and the patient is not ambulatory.
NEMT under Medi-Cal is covered only when the
patients’ medical and/or physical condition does
not allow them to travel by bus, passenger car,
taxicab, or other form of public or private
conveyance.
NMT Includes transportation for medically necessary
appointments and may be provided via taxi, sedans, or
other private conveyance.
Select the type of transportation required:
NEMT NMT
Based on the above information, what type of transportation does the member require?
NEMT:
Wheelchair
Gurney/stretcher
Ambulance
NMT:
Sedan/Taxi
Private conveyance
If you have selected NEMT, please describe what is preventing the patient from using non-medical
transportation. Failure to complete this section will cause the PCS form to be sent back to the
physician for completion.
Will the member use one of the following support aids during the transport?
Wheelchair Walker Cane Other
If you selected “other,” please explain:
CERTIFICATION: The physician, dentist or podiatrist responsible for providing care for the member is responsible for the
determining medical necessity for transportation. This Certificate can be complete and signed by an MD, LVN, RN, PA, NP or
discharge planner who is employed or supervised by the hospital, facility or physician’s office
where the patient is being treated
and who has knowledge of the patient’s condition at the time of completion of this Certificate.
TBSP11033 (5/20)
blueshieldca.com/promise
Duration of transportation service based on continued health plan eligibility
Dates of service:
(maximum 12 months)
Effective date:
End date:
Staff/Physician’s signature:
Date:
Staff/Physician’s name: (typed or printed)
Title:
Contact phone number:
Pleas
e return this completed and signed form to Blue Shield Promise.
If the
member will require NMT Transportation, please send this form using the address or FAX number
below:
Postal address:
Blue Sh
ield of California Promise Health Plan
Attn: Utilization Management
601 Potrero Grande Drive
Monterey Park, CA 91755
FAX number:
(323) 889-2105
If the
member will require NEMT Transportation, please FAX this form with a Treatment Authorization
Request to Utilization Management.
FAX number for standard requests:
(323) 889-6506
FAX number for urgent requests:
(323) 889-5403
As a reminder, to qualify as “urgent,” the request must meet the following rule:
Califo
rnia Health and Safety Code sections 1367.01(h)(2)
(2) When the enrollee's condition is such that the enrollee faces an imminent and serious threat to his or
her health including, but not limited to, the potential loss of life, limb, or other major bodily function, or
the normal timeframe for the decision making process, as described in paragraph (1), would be
detrimental to the enrollee's life or health or could jeopardize the enrollee's ability to regain maximum
function, decisions to approve, modify, or deny requests by providers prior to, or concurrent with, the
provision of health care services to enrollees, shall be made in a timely fashion appropriate for the nature
of the enrollee's condition, not to exceed 72 hours after the plan's receipt of the information reasonably
necessary and requested by the plan to make the determination.
If you
have questions, please contact Blue Shield Promise at (877) 433-2178, 8 a.m. to 5 p.m., Monday
through Friday.
TBSP11033 (5/20)
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Outpatient Treatment Authorization Request (Blue Shield of California)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 4 March 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document