Prior Authorization Request This form meets HIPAA standards to protect individuals' personal health information. All fields must be completed and clinical records included. STANDARD RETROSPECTIVE URGENT For URGENT requests, check below to attest that the member's condition meets one of the following: *Please choose at least one of the following: Condition seriously jeopardizes the life or health of the member Condition seriously jeopardizes the member's ability to attain, maintain or regain maximum function Condition subjects the person to uncontrolled pain URGENT requests may be downgraded to standard if they do not meet at least one of the above criteria. Standard Request Turnaround Time: Medicaid and CHP+ - 10 days Medicare - 14 days / Part B Drugs - 72 hours Employer Group Plans / Elevate - 15 days Retrospective Turnaround Time: 30 days Concurrent Request (This is a request to extend treatment beyond the initial approved time period; request must be made 24 hours before the expiration of the authorized time period) Turnaround time: 24 hours Urgent Request Turnaround time: 72 hours/ 24 hours for Urgent Part B Drugs MEMBER INFORMATION: Name (Last, First, Middle Initial)* Member DOB* Member ID #* Member's Primary Care Physician Member Gender Assigned at Birth Male Female ORDERING/REQUESTING PROVIDER INFORMATION: Provider Name* Contact at Provider Office Requesting Facility* Provider NPI #* Provider Phone #* Provider Fax #* Servicing Facility or Provider Information: Specialty* Facility Name* Contact Name* Phone #* Fax #* Tax ID # NPI #* Requested Services: Inpatient Service Outpatient Service Diagnosis ICD 10 Codes* 1. Requested Service Description of Requested Service:* CPT/HCPCS Code:* Start of Care (If Requesting Home Health Care): Start Date:* End Date:* # of Visits/Units:* DME Only: Rental or Purchase 2. Requested Service Description of Requested Service: CPT/HCPCS Code: Start Date: End Date: # of Visits/Units: DME Only: Rental or Purchase 3. Requested Service Description of Requested Service: CPT/HCPCS Code: Start Date: End Date: # of Visits/Units: DME Only: Rental or Purchase 4. Requested Service Description of Requested Service: CPT/HCPCS Code: Start Date: End Date: # of Visits/Units: DME Only: Rental or Purchase 5. Requested Service Description of Requested Service: CPT/HCPCS Code: Start Date: End Date: # of Visits/Units: DME Only: Rental or Purchase Additional Information You Would Like Us to Know: ATTACH SUPPORTING DOCUMENTATION: IMPORTANT: to upload more than one document, select all documents from your computer. On Windows hold ctl-key and click to select more than one file. On Mac, hold apple-key and click to select more than one file. DOWNLOAD FORM DATA (PRIOR TO SUBMISSION): If you would like to download the data you have entered in this form, click on the 'Download Form Data' button below. A CSV file that contains the data you are providing in this form will be downloaded to your computer. You need to click the 'Download Form Data' button after you have completed the form but before you click on the 'Submit Form' button. Download Form Data SUBMIT FORM: You must complete all required fields prior to submission. To ensure files and data are successfully submitted, do not close this window until you see a 'Thank You' confirmation page. Submit Form * Field is required