Fillable Prior Authorization Request

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Prior Authorization Request

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The Prior Authorization Request form is 2 pages long and contains:

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  • 1 check-box
  • 94 other fields

Country of origin: OTHERS
File type: PDF

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Member
Information
Name:
Devoted Health Member ID: Birth Date: (MM/DD/YY)
D
/
/
Information
About You
(the person filling
out this form)
Name:
Phone: Fax:
Who Is
Requesting
Care?
Provider or Facility Name: NPI Number:
Specialty: Devoted PCP ID:
LX
Who Will
Provide Care?
Provider or Facility Name: NPI Number:
Address:
Specialty: Tax ID Number:
Prior Authorization Request
PROVIDERS: For a faster turn-around, go to www.devoted.com/providers and
submit your request through the Availity Provider Portal.
Fax your completed form and documentation to 1-877-264-3872.
Devoted Health is an HMO plan with a Medicare contract. Enrollment in Devoted Health depends on contract renewal.
Questions? Call provider services at 1-877-762-3515. Y0142_20M194_C
Fax your completed form
and documentation to:
1-877-264-3872
Type of Care
Please be sure to fill in this section completely so we can respond as quickly as possible — all fields are required.
!
Attach any important clinical documentation that supports your request.
Request Type: Inpatient Service/Procedure
Service Type:
Inpatient Referral Surgery Home Health Care
DME PT/OT/ST Chemotherapy Radiation Therapy
Diagnostic Diagnostic Part B Other
Imaging
Testing
Non-Oncology
Location:
Office ASC Home Other
Outpatient Outpatient Imaging
Hospital
Rehab
Center
Start Date: (MM/DD/YY) End Date: (MM/DD/YY) Number of Visits/Units:
/
/
to
/
/
ICD-10 Code(s): Diagnosis:
Procedure Code(s):
Urgent Requests
Check this box only if you need an expedited response. For Part B drug requests, standard response time is 72 hours.
Expedited response time is 24 hours. For all other requests, standard response time is 3-14 calendar days. Expedited
response time is 72 hours.
This is an urgent request. Waiting more than 72 hours (or more than 24 hours for a Part B drug) could harm the
member’s health.
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Prior Authorization Request

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Completed 12 November 2020

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