Read Microsoft Word - Radiology Prior Authorization Request Form_COR 88_10-1-09.doc text version

Radiology Prior Authorization Request Form

This form is used to obtain prior authorization for elective outpatient services or update an existing outpatient authorization. All fields marked with an asterisk (*) are required. The information in Section 2 is only required for updated or retroactive authorizations. Forms that are submitted without all of the required information will be returned for correction. Telephone number: 1-800-572-2116 Fax number: 1-800-572-2119 Please check the appropriate action requested: *Date of Request: / /

CT Scan

*Name:

CTA Scan

MRI Scan MRA Scan PET Scan

Client Information *Medicaid number: Facility Information

Cardiac Nuclear Scan Update/change codes from

original PA request *Date of Birth: / /

*Name: *Address: TPI: Taxonomy: *NPI: Benefit Code:

Reference number:

Requesting/Referring Physician Information *Name: *Address: *Telephone: TPI: Taxonomy: *Fax number: *NPI: Benefit Code: License number:

Section 1

Service Types Date of Service: Diagnosis Codes

*Outpatient Service(s)

/ *Primary: /

Emergent/Urgent Procedure *Procedures Requested: Secondary:

*Clinical documentation supporting medical necessity for a radiology procedure includes treatment history, treatment plan, medications, and previous imaging results:

*Requesting/Referring Physician (Signature Required): *Print Name: *Date: / /

Section 2--Updated Information (when necessary)

*Date of Service: Diagnosis Codes / *Primary: / *Procedures Requested: Secondary:

*Clinical documentation supporting medical necessity for a procedure code change includes treatment history, treatment plan, medications, and previous imaging results:

*Requesting/Referring Physician (signature required): *Print Name: Physician must complete and sign this form prior to requesting authorization. *Requesting/Referring Physician NPI: *Date: / /

Requesting/Referring Physician License No.: Requesting/Referring Physician TPI:

Effective Date_02012010/Revised Date_10012009

Information

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