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Prior Authorization Request Form

P hone: ( 832)828-1 004 ( 800)900-T C P ( H 8247) F ax: ( 832)825-8760 P re-certification is a condition of reimbursement. I is not a guarantee of payment. I is the responsibility of each provider to verify the t t member' eligibility prior to rendering services. P roviders should initiate the prior authorization process 3-5 business days prior to a s scheduled service. A response will be given within 72 hours. An incomplete Pre-certification Request Form will delay processing of your request. D _______________________ Name of P erson C ate: ompleting F orm: ________________________________________________ Office Number: ___________________________________ F Number: _____________________________________________ ax M ember Name: ________________________________________________ M ember I Number: ____________________________________________ D P rimary C P rovider: ___________________________________ are R equesting P rovider Name: _______________________________ F acility: _______________________________________________ D iagnosis: _____________________________________________ P rovider T P I _____________________________________ : P rovider T P I _____________________________________ : P rovider T P I _____________________________________ : I D C s) ____________________________________ C -9 ode( : D : _______________________ S ex: M or F OB

S ervice( / rocedures( Y ou are R equesting: _____________________________________________________________________ s)P s) ___________________________________________________________________________________________________________ D of S ervice: _____________________________ Estimated LOS R equired: ___________________________________ ate

(Number of days requesting)

M edical H istory ( Please attach all documentation relevant to the requested procedure) R equired for review. ___________________________________________________________________________________________________________ Place of Service H C C / P T 4 C s) P SC ode( : 1 . _________________ 2. _________________ 3. _________________ 4. _________________ V isits/ nits: U 1 . ______________ 2. ______________ 3. ______________ 4. ______________ M edicaid T ype of S ervice C ode: I npatient 1 . ________________ 2. ________________ 3. ________________ 4. ________________ Outpatient P hysician' s Office H ome D ay S urgery Observation

Other I nsurance: __________________________________ (PLEASE DO NOT WRITE BELOW THIS LINE.) Approved D enied

Other I nsurance P hone #: ___________________________________

Effective D ______________________ ate: Expiration D _____________________ ate:

Authorization Number: ____________________________________________

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