Texas Standard Prior Authorization Request Form For Health Care Services

Download a blank fillable Texas Standard Prior Authorization Request Form For Health Care Services in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Texas Standard Prior Authorization Request Form For Health Care Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

T
S
P
A
R
F
H
C
S
EXAS
TANDARD
RIOR
UTHORIZATION
EQUEST
ORM FOR
EALTH
ARE
ERVICES
Clear Form
Print
S
I — S
ECTION
UBMISSION
Issuer Name:
Phone:
Fax:
Date:
S
II — G
I
ECTION
ENERAL
NFORMATION
Review Type:
Non-Urgent
Urgent
Clinical Reason for Urgency:
Request Type:
Initial Request
Extension/Renewal/Amendment
Prev. Auth. #:
S
III — P
I
ECTION
ATIENT
NFORMATION
Name:
Phone:
DOB:
Male
Female
Other
Unknown
Subscriber Name (if different):
Member or Medicaid ID #:
Group #:
S
IV ― P
I
ECTION
ROVIDER
NFORMATION
Requesting Provider or Facility
Service Provider or Facility
Name:
Name:
NPI #:
Specialty:
NPI #:
Specialty:
Phone:
Fax:
Phone:
Fax:
Contact Name:
Phone:
Primary Care Provider Name (see instructions):
Requesting Provider’s Signature and Date (if required):
Phone:
Fax:
S
V ― S
R
(
CPT, CDT,
HCPCS C
)
S
D
(
ICD C
)
ECTION
ERVICES
EQUESTED
WITH
OR
ODE
AND
UPPORTING
IAGNOSES
WITH
ODE
Planned Service or Procedure
Code
Start Date
End Date
Diagnosis Description (ICD version___)
Code
Inpatient
Outpatient
Provider Office
Observation
Home
Day Surgery
Other: __________________
Physical Therapy
Occupational Therapy
Speech Therapy
Cardiac Rehab
Mental Health/Substance Abuse
Number of Sessions: ___________ Duration: ________________ Frequency: ___________ Other: _______________________
Home Health (MD Signed Order Attached?
Yes
No)
(Nursing Assessment Attached?
Yes
No)
Number of Visits: _____________ Duration: ________________ Frequency: ___________ Other: _______________________
DME (MD Signed Order Attached?
Yes
No)
(Medicaid Only: Title 19 Certification Attached?
Yes
No)
Equipment/Supplies (include any HCPCS Codes): _____________________________________ Duration: __________________
S
VI ― C
D
(S
I
P
, S
VI)
ECTION
LINICAL
OCUMENTATION
EE
NSTRUCTIONS
AGE
ECTION
An issuer needing more information may call the requesting provider directly at: _______________________________________
NOFR001 | 0415
Page 2 of 2

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Nofr001 - Texas Standard Prior Authorization Request Form For Health Care Services Form Nofr001 - Texas Standard Prior Authorization Request Form For Health Care Services Legal
Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance Medical
Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance Legal
Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance Texas Standard Prior Authorization Request Form For Health Care Services Form - Department Of Insurance Legal
Form Nofr002 - Texas Standard Prior Authorization Request Form For Prescription Drug Benefits Form Nofr002 - Texas Standard Prior Authorization Request Form For Prescription Drug Benefits Medical
Form Fis 2288 - Michigan Prior Authorization Request Form For Prescription Drugs - Department Of Insurance And Medical Services Form Fis 2288 - Michigan Prior Authorization Request Form For Prescription Drugs - Department Of Insurance And Medical Services Legal
Standard Prior Authorization Request Form - United Healthcare Standard Prior Authorization Request Form - United Healthcare Medical
Prior Authorization Request Form - Alliant Health Plans Prior Authorization Request Form - Alliant Health Plans Medical
Prior Authorization Request Form For Prescription Drugs - Us Script Prior Authorization Request Form For Prescription Drugs - Us Script Business
Form Frx013 - Prior Authorization Request Form For Multiple Sclerosis Betaseron/copaxone/rebif Form Frx013 - Prior Authorization Request Form For Multiple Sclerosis Betaseron/copaxone/rebif Medical

Related Categories

Parent category: Medical
Download
Go
Page of 3