8/
19/19 PHP Form
Me
mber Name
Da
te of Birth
Me
mber’s Plan ID
Is
Referring Provider: Plan NP
Na
me of Nursing Facility Referring Provider
PCP
Plan PA Other
Diagnoses (ICD-10 Codes) Related to Auth Request
Date of Procedure/Service: _____________________CPT Code or Name of Procedure/Service: ____________________
Pro
vider Name (REQUIRED): _________________________________________________________________
S
Provider Contact Number (REQUIRED): _________________________________________________________
Provider Specialty (REQUIRED): _______________________________________________________________
In Network (REQUIRED): Circle Correct Answer: YES NO Number of Visits Requested: ______
Vendor Name (REQUIRED): ___________________________________________________________________
Ve
ndor Contact Number (REQUIRED): __________________________________________________________
Sp
ecialty (REQUIRED): ________________________________________________________________________
In Network (REQUIRED): Circle Correct Answer: YES NO Number of Visits Requested: _________
TO
BE COMPLETED BY PERSON REQUESTING AUTHORIZATION
Na
me of Person Completing this Form:
Date Completed:
(Please Print Name)
Co
ntact #:
Co
ntact FAX:
*PR
IOR AUTHORIZATION IS REQUIRED FOR SERVICES BY ANY NON-PARTICIPATING PROVIDER. (ATTACH OON FORM)
Payment is
authorized only for the medical services noted below, and is subject to the limitations and exclusions as outlined in the Member
Handbook/Certificate of Coverage.
Mem
ber Data
He
althCare Professional
Tel
ehealth
Se
rvice
SER
VICES REQUESTED
Refer
ral-include copy of order PA-include clinical Out of Network- (ATTACH OON FORM)
REQUEST FOR REFERRAL & PRIOR AUTHORIZATION FOR TELEHEALTH
REQUEST FOR PRIOR
AUTH TO
OTHER HEALTHCARE PROFESSIONAL
FAX Form and Clinical to 833-610-2399
*** PLEASE DO NOT SEND REQUESTS FOR MULTIPLE MEMBERS TOGETHER IN ONE FAX – MUST SEND SEPARATELY
Call UM at: 1-855-855-0668 (GA) or 1-855-855-0759 (NC/SC)
(Call Center Hours: 8am – 8pm LOCAL TIME)
