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Prior Authorization REQUEST LINE OF BUSINESS …

Please type into PDF form and fill out all fields. Fax completed form to 650-829-2079. Today's Date: MM_____-DD YYYY Is this a Pharmacy request?

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Text of Prior Authorization REQUEST LINE OF BUSINESS …

Please type into PDF form and fill out all fields. Fax completed form to 650-829-2079. Today's Date: ___________________ MM-DD-YYYY Is this a Pharmacy request? YES NO IF YES, FAX Form to 650-829-2045 Is this a retrospective request? YES NO IF YES, FAX to 650-829-2062 Is member currently in the hospital? YES NO IF YES, FAX Facesheet to 650-829-2060 Member Last Name: _________________________________ First Name, : ________________________________________ Street Address: ________________________________________ _ City, State, ZIP: ________________________________________ _ Phone: __________________________ Member ID#: ___________________________ DOB: _________________ Age: __________ Servicing Provider Name: ________________________________________ ___________ NPI: ___________________________ Street Address: ________________________________________ _ City, State, ZIP: ________________________________________ _ Phone: __________________________ Fax: _________________________ Office Contact: _________________________________ Additional Provider (if needed): ________________________________________ ________ NPI: ___________________________ Primary Diagnosis Code: _________________ Description: ________________________________________ _________________ Secondary Diagnosis Code: _________________ Description: ________________________________________ _________________ Tertiary Diagnosis Code: _________________ Description: ________________________________________ _________________ Optional comments for medical justification. Requesting Provider please attach required medical records/supporting documents. To the best of my knowledge, the above information is true, accurate and complete, and the requested services are medically indicated and necessary to the health of the patient. Signature of Physician or Provider Title Date MM-DD-YYYY 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 TEL: 650-616-0050 TTY: 1-800-735-2929 For authorization questions contact HPSM Health Services Ph 650-616-2070 Fax 650-829-2079 For Facesheets fax to 650-829-2060 NOTE: AUTHORIZATION DOES NOT GUARANTEE PAYMENT. PAYMENT IS SUBJECT TO PATIENT S ELIGIBILITY. BE SURE THE ID CARD IS CURRENT BEFORE RENDERING SERVICE. Version March 2017 Line No. Procedure Code (CPT/HCPCS Code/Modifier if applicable) Specific Services Requested Units of Service (Days/Quantity) 1 2 3 4 5 6 7 8 9 10 Prior Authorization Request Form Requested Service Dates FROM: MM-DD-YYYY TO: MM-DD-YYYY REQUEST URGENT ROUTINE LINE OF BUSINESS CAREADVANTAGE MEDI-CAL ACE HEALTHYKIDS HEALTHWORX Long Term Care (LTC) Required Information (Mark or X): Transfer Initial Reauthorization Bed Hold Skilled Nursing ICF-DD Sub-Acute Mark or X

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