Questions? Call provider services at 1-877-762-3515. Y0142_20M194_C
Fax your completed form
and documentation to:
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
Inpatient Referral Surgery Home Health Care
DME PT/OT/ST Chemotherapy Radiation Therapy
Diagnostic Diagnostic Part B Other
Office ASC Home Other
Outpatient Outpatient Imaging
Start Date: (MM/DD/YY) End Date: (MM/DD/YY) Number of Visits/Units:
ICD-10 Code(s): Diagnosis:
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