Prior Authorization Request Form - Alliant Health Plans
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1
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3PRIOR AUTHORIZATION REQUEST FORM
Providers have access to submit prior authorizations online. To register, visit
DATE OF REQUEST:
MM/DD/YYYY
SCHEDULED DATE OF SERVICE:
MM/DD/YYYY
PROVIDER INFORMATION
Referring Physician Name:
Form Completed By:
Phone Number:
Fax Number:
Patient Name:
Member ID Number:
ICD-10 code or Diagnosis:
CPT:
SERVICE INFORMATION
Provider Name:
Observation
Inpatient
Outpatient
Ancillary
PT
Type of Service (Please Select):
OT
ST
Home Health
Hospice
DME
HCPC(s):_____________________________________
Required for DME
CLINICAL INFORMATION
Please provide comments/clinical/supporting information to expedite the authorization:
Physician Signature
(Required):
X
COMPLETED BY ALLIANT MEDICAL MANAGEMENT:
Authorization Number:
Effective Date:
Expires:
Initial Inpatient LOS (if applicable):
Amount of Outpatient services approved:
Submit To Fax #: 866-370-5667
For Questions Call: 800-865-5922
AHP - PRIOR AUTHORIZATION REQUEST FORM
Rev. 8-30-16
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