Prior Authorization Request Form

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Prior Authorization Request Form
Fax: 313-745-0399
Medical Management Phone: 877-501-0958
Inpatient
Outpatient
Date of Request:
Date of Service:
_____________
_____________
Member’s Name: ________________________________________________
DOB: ________________
DMC Care ID#: ______________________________
Other Insurance: _____________________________________
Requesting Physician: ____________________________________ Specialty: ___________________________________
Address: _______________________________________________________________________________________________
Contact Person: _______________________________
Phone#: __________________ Fax#: ___________________
Facility Name: ________________________________________
Phone#: _______________________________
Address: _______________________________________________________________________________________________
NPI #: _________________________________
Provider Tax ID #: _____________________________________
Diagnosis: ____________________________________________ ICD10 Code: ___________________________________
Procedure: ____________________________________________
CPT-4 Code: ____________________________
___________________________________
HISTORY/SUPPORTING DOCUMENTATION: INCLUDE CLINICAL DOCUMENTATION TO SUPPORT MEDICAL NECESSITY (I.E.
SYMPTOMS, PREVIOUS TREATMENT LAB, RADIOLOGY RESULTS & PROGESS NOTES IF APPLICABLE)
SERVICES NOT AVAILABLE IN THE DMC/TENET NETWORK (PLEASE PROVIDE SUPPORTING DOCUMENTATION)
COMMENTS
MEDICAL MANAGEMENT USE ONLY:
Denied
Approved:
Authorization#: ___________________
Date: _____________________
No Authorization Required
Services will be provided outside the DMC/Tenet Network
PROVIDER MUST NOTIFY MEMBER: CO- PAYS, COINSURANCE & DEDUCTIBLES WILL APPLY FOR THIS SERVICE
A
D
NOT G
P
. P
D
E
D
S
UTHORIZATION
OES
UARANTEE
AYMENT
AYMENT
EPENDENT ON
LIGIBILITY ON
ATE OF
ERVICE
AUTHORIZATION IS NOT INCLUSIVE OF GAP EXCEPTION
CONFIDENTIALITY NOTICE: This message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and/or privileged
information. If you are not the intended recipient(s), you are hereby notified that any dissemination, unauthorized review, use, disclosure or distribution of this
communication and any materials contained in any attachments is prohibited. If you receive this message in error, or are not the intended recipient(s), please immediately
notify the sender and destroy all copies of the original message, including attachments.
DMC Care 2016
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