Chiropractic Treatment
Pre-Authorization/Prior Approval Request Form
Fax form and relevant clinical documentation to (651) 662-7816
Member ID: _______ ____________________
Group number: _________________
Member name: _____________________________________
Date of birth: ___________________
Member address: _____________________________________________________________________
Member city/state/zip: _________________________________________________________________
Member phone: _______________________
Primary diagnosis code: _________________
Diagnosis description: ____________________________
Secondary diagnosis code(s): _____________
Diagnosis description: ____________________________
Medicare or another insurance primary:
Yes
No
Request type:
Initial
Ongoing
Has patient seen another chiropractor in this calendar year?
Yes
No
st
Number of visits from January 1
of current year to start date on this request: ______
Contact person: ________________________
Phone: _______________________
Provider name: ________________________________________________________________
Provider ID/NPI number: ________________________
Provider address: ______________________________________________________________________
City/state/zip: ________________________________________________________________________
Provider phone: _______________________
Provider fax: ____________________
Is the Servicing Provider participating with the local Blue Plan?
Yes
No
Chief complaint: ______________________________________________________________________
Initial date of service: _____________
Date of onset/exacerbation for this condition: _____________
Clinical presentation:
Acute
Sub-Acute
Chronic
Recurrent
Spinal Stenosis
Date of initial exam/Re-exam: _____________
Patient’s rating per Pain Severity Scale Initial: ___/10
Current: ___/10
Patient history related to this diagnosis:
Is there a functional impairment related to this diagnosis?
Yes
No
If yes, please explain:
Mild
Moderate
Severe
Provide examples of progressive improvement with functional impairment:
Other significant history/medical/medications/treatment information:
X17782R02 (02/14)
An independent licensee of the Blue Cross® and Blue Shield® Association serving residents and businesses of Minnesota.
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