TREATMENT AUTHORIZATION REQUEST

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Reason for Request: Prior. Treatment. &. Results: Relevant labs/X-Rays, etc: □ Health ... DENIAL. AUTH #:_. Date Approved: Date Auth. Expire: Comments: Reviewer's Name: Signature:_. Date: CARE 1st USE ONLY: Member Eligibility as of:.
601 Potrero Grande Drive, Monterey Park, CA 91755 Telephone: (323) 889-6638 UM Direct FAX Line: (323) 889-6577

San Diego Fax Line (323) 889-6506

TREATMENT AUTHORIZATION REQUEST URGENT

 ROUTINE

 RETROACTIVE PRIMARY LANGUAGE SPOKEN:_ Require Interpreter:  Y  N  American Sign Language DOB: GENDER :  F  M

I. PATIENT INFORMATION Member Name: Member Address:

City:

Zip:

Member ID#:

 Medicare

 Medi-Cal

Phone:

 Healthy Families

 Commercial

II. REFER TO INFORMATION Date of Request:

Provider Name:

Specialty:

Provider Address:

Phone:

Facility Name:

Fax:

Phone:_

Fax:

III. SERVICE(S) REQUESTED  Initial Consult

 FU visit(s)

 Inpatient Admission

 Home Health

 Outpatient procedure(s)

 Social Services

 DME

Other:

Diagnosis:

ICD 9 CODE(S):

Service(s)/Procedure(s):

CPT 4 CODE(S):

Reason for Request: Prior

Treatment

&

Results:

Relevant labs/X-Rays, etc: Health Education (Specify): Requesting Physicians Name (PLEASE PRINT)

Physician’s Signature Accident:  YES  NO UM Decision Status: AUTH #:_

PCP Phone: ( FAX: (

Where Occurred:  Home  Work  Auto 

APPROVED



MODIFIED

Date Approved:





)

Other  DENIAL Date Auth. Expire:

DEFERRED

Comments:

Reviewer’s Name:

Signature:_

CARE 1st USE ONLY: Member Eligibility as of:  IPA RESPONSIBILITY, Date faxed to IPA:

Date: PCP Provider ID #:

THIS REFERRAL DOES NOT GUARANTEE ELIGIBILITY. CHECK ELIGIBILITY PRIOR TO RENDERING SERVICE. Payment will NOT be made for unauthorized services. All lab and x-rays must be ordered/performed by contracting providers (contact Care1st Health Plan U.M. Department at above number if unsure). Specialist reports must be sent to PCP promptly.

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