Fillable PRIOR AUTHORIZATION REQUEST FORM Request Type: Initial Request

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PRIOR AUTHORIZATION REQUEST FORM Request Type: Initial Request

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Inpatient Outpatient Provider Office Observation Home Day Surgery Other: __________________
___________ Duration: ________________ Frequency: ___________ Other: _______________________
PRIOR AUTHORIZATION REQUEST FORM
Review Type: Non-Urgent Urgent Clinical Reason for Urgency:
Name: Phone: DOB:
Member ID #:
PATIENT INFORMATION
Group #:
Issuer Name: Phone: Fax: Date:
Name: NPI #:
Specialty: Phone: Fax:
PROVIDER INFORMATION
Requesting Provider or Facility
Physical Therapy Occupational Therapy Speech Therapy Cardiac Rehab Mental Health/Substance Abuse
Number of Sessions:
SERVICES REQUESTED (WITH CPT, CDT, OR HCPCS CODE) AND SUPPORTING DIAGNOSES (WITH ICD CODE)
Planned Service or Procedure Start Date End Date Diagnosis Description (ICD code___)
CLINICAL DOCUMENTATION (Please attach clinical documentation to support request)
Request Type: Initial Request Extension/Renewal/Amendment Reconsideration
402 Graham Avenue ● PO Box 1128 ● Eau Claire, WI 54702-1128 ● Phone: (800)236-7789 ● (715)832-5535 ● FAX: (715)930-1305
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PRIOR AUTHORIZATION REQUEST FORM Request Type: Initial Request

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Completed 8 November 2021

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