Provider Prior Authorization Form
Fax medical authorization requests to: 1.855.328.0059
Phone: Toll-Free 1.844.522.5282 /TDD Relay 1.800.955.8771
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COMPLETE ALL INFORMATION
REVIEW TYPE Standard (≤ 14 days) Accommodate scheduling/patient needs (Date needed: _______________)
Check one
Urgent (≤ 72 hours)
Provider certifies that the standard review time frame would seriously jeopardize the member’s life or health.
Clinical reason for urgency: _____________________________________________________________________
Practitioner signature: _________________________________________________________________________
==========================================================================================================
DATE OF REQUEST______________
REQUEST TYPE - Check all that apply
Initial request Change to initial request - Auth #:_________________ Addition to initial request - Auth #:___________________
Second medical opinion (Provide reason): ____________________________________________________________________________
Out-of-network provider request (Provide reason): _____________________________________________________________________
==========================================================================================================
MEMBER ID#:___________________ MEMBER NAME (FIRST/LAST):__________________________________ DOB:______________
REQUESTING PROVIDER NAME (FIRST/LAST):_______________________________________________________________________
PROVIDER CONTACT NAME:______________________________ Phone: (_____)____________ Ext._____ Fax: (_____)____________
PERFORMING/SERVICING PROVIDER: Check if same as Reques
ting Provider NPI or TIN ___________________________
Name (First/Last):________________________________________ Specialty:________________________________________________
Address: __________________________________________________________ Phone: (_____)___________ Fax: (_____)___________
FACILITY/SUPPLIER: Check if same as Requesting Provider NPI or TIN ___________________________
Name:__________________________________________________________________________________________________________
Address: ___________________________________________________________ Phone: (_____)___________ Fax: (_____)__________
Check applicable place of service below AND complete requested information.
COMPLETE APPLICABLE INFORMATION
PLACE OF SERVICE: Office (11) Home (12) Inpatient Hospital (21) Outpatient Hospital/Observation (22)
Ambulatory Surgery Center (24) SNF (31) Other _______________________________________
REQUESTED DATES OF SERVICE: From: _____________
To: ______________
REQUESTED
CPT/HCPCS CODE(S)
REQUESTED
CPT/HCPCS CODE DESCRIPTION(S)
# VISITS/ DAYS/
UNITS
REQUESTED
ICD CODE(S) DIAGNOSIS (ICD CODE) DESCRIPTION(S)
DME: Bilateral Right Left / Purchase Rental / Initial Subsequent
AUTHORIZATION DOES NOT GUARANTEE COVERAGE
AND DOES NOT SUPERSEDE ANY MEMBER BENEFIT LIMITS OR PROVIDER CONTRACTUAL LIMITS.
CONFIDENTIALITY: The information contained in this facsimile message may be legally privileged and confidential information intended only for the use of the individual or entity
named above. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this telecopy is strictly
prohibited. If you have received this telecopy in error, please immediately notify the sender above and return the original message to us at the address above by the United States
Postal Service. Thank you for your cooperation.
AFFIRMATIVE STATEMENT: UM decision-making is based only on appropriateness of care and service and existence of coverage. Health First Health Plans does not
specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision-makers do not encourage decisions that result in under-
utilization.
Health First Health Plans is an HMO plan with a Medicare contract. Enrollment in Health First Health Plans depends on contract renewal. Health First Commercial Plans, Inc. and
Health First Insurance, Inc. are both doing business under the name of Health First Health Plans. Health First Health Plans does not discriminate on the basis of race, color,
national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.
LAST REVISED: 5/2018 – Apply updates to Y0089_MPINFO6651 (05/18)
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