MedMutual.com
PCAT-1203 2/4/16
Patient Information
Patient Name (Last, First) Date of Birth (mm/dd/yyyy)
Mailing Address (Street, City, State & Zip)
+FGPVKſECVKQP0Q
Daytime Phone )TQWR0Q
Provider Information
Provider Name (Last, First) 02+0Q
Mailing Address (Street, City, State & Zip)
Phone Number
4GSWGUVGT6KVNGKHFKHHGTGPVVJCPRTGUETKDGT
Phone Number
Provider Signature
Date
(QT)GPGVKE6GUVKPIō.CD2GTHQTOKPI6GUV
Provider Name 02+0Q Z Code
Mailing Address (Street, City, State & Zip)
2JQPG0Q
Reason for Prior Approval
T2TQEGFWTGT&WTCDNG/GFKECN'SWKROGPV&/'T&GXKEGT/GFKECVKQPō+PLGEVCDNGCPF+PHWUKQP%QORNGVG/GFKECVKQP2TKQT#RRTQXCNUGEVKQPQPN[
T)GPGVKE6GUVT1VJGTō&GUETKDG
&GUETKRVKQPQH5GTXKEG2NGCUGURGEKH[GZCEVUGTXKEGUDGKPITGSWGUVGF
Diagnosis
ICD-10-CM Diagnosis Code(s)
Is this an established diagnosis for the patient?
TYes TNo
CPT/HCPCS Code(s)
0COGCPFRNCEGQHUGTXKEGT1HſEGT+P1WVRCVKGPV(CEKNKV[T Home T SNF T1VJGTō&GUETKDG
+UVJGTGRTGXKQWUJKUVQT[QHUGTXKEGUTGNCVKPIVQVJKURTKQTCRRTQXCN!T Yes T0Q+H[GURNGCUGFGUETKDG
/GFKECN0GEGUUKV[5VCVGOGPVCPF&QEWOGPVCVKQP
6JGHQNNQYKPIFQEWOGPVCVKQPKUGPENQUGFHQTTGXKGYQHVJKURTKQTCRRTQXCNTGSWGUVŗ
T1HſEG0QVGUT/GFKECN4GEQTFUT X-rays T Photos T1VJGTō&GUETKDG
Prior Approval Form
2NGCUGRTKPVYKVJDNCEMKPMQTſNNKPWUKPI#FQDG
®
4GCFGT
®
(QTCNKUVQHOGFKECVKQPUCPFUGTXKEGUTGSWKTKPIRTKQTCRRTQXCNQTEQPUKFGTGFKPXGUVKICVKQPCNXKUKVVJG6QQNU
4GUQWTEGU%CTG/CPCIGOGPV
2TKQT#RRTQXCN+PXGUVKICVKQPCN5GTXKEGU4GUQWTEGU
UGEVKQPQH2TQXKFGT/GF/WVWCNEQO
Date:__________________
Other
—DescribeOut of Network Waiver
NPI No.
Fax Number
Z3323-PRV R12/19
