PLEASE COMPLETE FORM AND
ATTACH WITH CLINICAL RECORDS
Please contact the benefit department via the phone number on the insureds medical ID
card for benefits on the procedure you are inquiring on to determine if prior authorization is
required. The benefit department would advise level of coverage or if care is non-covered
within the plan the patient has.
To: PRIOR AUTHORIZATION DEPT
From: ________________________
Patient name: _______________________________ Patient’s DOB: _____________
ID # _______________ Group #_________________
Ordering Physician: Credentials: __________________
Address: ____________________________________________________________________
City: State: Zip: _________________
Phone #: ________________________
Fax: ____________________________
Facility: _________________________________
Facility address: _________________________
Facility phone#: __________________________
DATE OF SERVICE: ________________________
ICD-10: ___________________________________
CPT CODE (5 digit code): please enter number of sessions desired for each CPT requested:
CPT: (_______) x ( ) sessions starting date ( ) to ending date ( )
CPT: (_______) x ( ) sessions starting date ( ) to ending date ( )
CPT: (_______) x ( ) sessions starting date ( ) to ending date ( )
F
OR PT/OT/ST/ABA
How many visits has patient used? ____________
Prior case # on file: __________________________
Information included in this document is considered to be UMR’s confidential and/or proprietary business
information. Consequently, this information may be used only by the person or entity to which it is addressed by
UMR for a legitimate purpose. Such recipient shall be liable for using and protecting UMR’s proprietary business
information from further disclosure or misuse. The report you have received may also contain protected health
information (PHI) and must be handled according to applicable law, including but not limited to HIPAA. Individuals
who misuse information may be subject to both civil and criminal penalties
