HI QExA PRIOR NOTIFICATION REQUEST FORM

Phone: 1-888-980-8728 Fax to: 1-800-267-8328 Today's Date: Please Print Patient Name: Date of Birth: Home Address: City, State and ZIP Code: Phone: URGENT: Yes No

MEMBER INFORMATION
Member ID#: Male Female

REQUESTING PHYSICIAN INFORMATION
Physician's Name: Contact Name: Physician / Authorized Signature: Specialty: Phone #: Fax #:

SERVICING PROVIDER INFORMATION
Treatment Request: Physician's Name: Facility Name: Office Contact Name: Service Setting (IP, OP, Office, other): Date of Service: From: PT / OT / Speech Therapy: Initial Request To: Continuing: Last DOS: OR Pending Authorization # of Visits: Scheduled Inpatient Surgery: ELOS Phone #: Fax #:

Requests for continuation of PT / OT / ST: Send initial and / or updated evaluation and progress notes along with physician's signature. Reason for Request:

Please attach clinical notes / documentation of medical necessity for requested service:

ICD9-CM CODE(S)

DIAGNOSES

CPT / HCPC CODE(S)

PROCEDURE(S) / TREATMENT(S)

# OF VISIT(S) (PT / OT / ST ONLY)

Durable Medical Equipment (DME):

Rental

Purchase

(Must include MD's order and medical documents with DME cost) Once approved, this notification in valid for the number of authorized visit(s), date(s) that are approved for the condition and only for the patient identified. NOTE: Coverage is dependent on member's eligibility and plan benefit at the time of service. Prior Notification Form (Rev. 12/09).

Sign up to vote on this title
UsefulNot useful