SECONDARY AUTHORIZATION REQUEST (SAR) FORM F
ax to 1-866-259-0311
SECTION I: PATIENT INFORMATION
Last Name: Fir st Name: DOB: SSN:
Address: City: State: Zip:
SECTION II: REQUESTING PROVIDER INFORMATION
Requesting Provider: Contact Person:
TI N: Phone:
Address: Fa x:
Specialty (type): Group Name:
SECTION III: TYPE OF CARE REQUEST
Please indicate CLINICAL urgency:
Routine Urgent Emergent
Urgent care is only applicable if a processing time of greater than 2 business days could
seriously jeopardize the life or health of the Veteran or their ability to regain maximum
function, OR would subject the Veteran to severe pain that cannot be adequately managed
without the care/treatment being requested. Do NOT mark urgent for administrative urgency.
Medically necessary emergent care should be rendered and documentation submitted later.
Diagnosis: (ICD-10 Code/Description):
Date of Service and/or Anticipated Length of Care:
CPT/HCPCS Code and/or Description
of Requested Service (include units/visits,
add second list page, if needed):
How many visits have occurred so far? (If known)
Is this a referral to another specialty? Yes No If yes, please fill out the Servicing Provider/Specialty information below.
Servicing Provider/Specialty: Contact Person:
TI N: Phone:
Address: Fa x:
Facility: Contact Person:
TI N: Phone:
Address: Fa x:
SECTION IV: TYPE OF SERVICES REQUESTED
PT OT Speech Therapy
Frequency and duration:
Surgical Procedure: Inpatient Outpatient
(List facility name in Section III & Complete Discharge Needs (Section VI))
In-Office Procedure Inpatient Care: SNF Acute Rehab BH
Additional Office Visits (list # needed):
Extension of Validity Dates
Labs: (If done outside of office, please provide a facility above) Radiology / Imaging (Utilize the facility box if outside of office)
Pre-Op Labs Chest XRAY EKG Other: Type & Screen Type & Cross
SECTION V: CLINICAL INFORMATION
To avoid delays in care, include appropriate documentation such as office notes, current treatment plans, clinical history, laboratory results,
radiology results and or medications to support the medical necessity of services requested. Additional information attached?: Yes No
Admission or
Discharge Information:
SECTION VI: DISCHARGE NEEDS
(Must be completed if requesting Inpatient Admission / Procedure)
DME – Item Description & HCPCS Codes
(to be provided by VAMC):
Home Health or Home Infusion Care –
List specific services, duration and/or frequency:
Skilled Nursing Facility Inpatient Acute Rehab
Other Needs:
To facilitate timely review of this request, the most recent office notes and plan of care must accompany this form. TriWest will
review for completeness and submit to VA if required. To submit a request, please fax to 1-866-259-0311.
If VA review is required, the turnaround time can be up to fourteen (14) calendar days. You can check the status of the request
on the provider portal at: www.triwest.com/provider
Revised May 2018
Previous Authorization Number:
