Phone: 602-
263-3000 or
800-624-3879
Fax: 800-217-9345
Prior
Authorization
Standard Request
Form
(Do not use this form for DME, Home Health, Therapy, ECT,
Psychological Testing, or for any Inpatient Behavioral Health Services)
Request completed by: Phone #:
Date of Request:
Total Number of Pages:
Important Note: Standard prior authorization requests are processed within 14 calendar days of receipt.
For urgent prior authorization requests please call 1-800-624-3879 to ensure optimal processing time.
Member Information
Member Name: Member ID #:
DOB:
Other Insurance: Yes No If yes, please specify:
Phone #:
Ordering Physician Information
Physician Name:
TIN/NPI #:
Address:
Phone #: Fax Number:
Contact Person:
Servicing Provider/Facility Information
Servicing Provider/Facility Name:
TIN/NPI #:
Address:
Phone
#:
Fax
#:
Dia
gnosis
Co
de
(s
)
:
CP
T
Co
d
e
(
s
)
:
Clinical Rationale for
service request:
Patient
History
Other
Ex
ams:
Significant
Signs
a
nd
Symptoms:
Duration
of
Symptoms:
Other
Treatments
Performed:
Please
include
supporting
document
which
might
include:
P
h
y
s
i
c
ian
Not
e
s
O
th
er
Lab
Results
Specialist
Consult
Notes
D
i
a
g
n
o
s
t
i
c Tests
Radiology
Results
Assessments
Medication
Lists
Important: To prevent delays in processing time, please provide completed documentation specific to this
request. Failure to do so may impact the final determination for this authorization.
Authorization does not guarantee payment. All authorizations are subject to member eligibility on the date
of service. If member is determined ineligible, the member may be responsible for these services. To
ensure proper payment for services rendered, referral provider/facility must verify eligibility on the date of
service. Verify benefit coverage in the benefit matrix located at
http://www.mercycareplan.com/mcp/members/covered_benefits.aspx.
