Alabama Prior Review And Authorization Request Form

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ALABAMA PRIOR REVIEW AND AUTHORIZATION REQUEST
Recipient Medicaid #_______________________________________
(Required If Medicaid Provider)
PMP (
)
Name __________________________________________________
Requesting Provider NPI #
_________________________________
Address ________________________________________________
Phone with Area Code
____________________________________
City/State/Zip ____________________________________________
EPSDT Screening Date ____________________ DOB ___________
Name
_____
_____________________________________________________
Prescription Date CCYYMMDD ______________________________
Rendering Provider NPI #
______________________________
First Diagnosis _______ ._______
Second Diagnosis _______ .______
Phone with Area Code
_____________________________________
Assignment/Service Code
Patient Condition
Prognosis Code
_____
_____
_____
Fax with Area Code
________________________________________
(01) Medical Care
(48) Hospital Inpatient Stay*
(75) Prosthetic Device
Name
__________________________________________________
(02) Surgical
(54) LTC Waiver
(A7) Psychiatric-Inpatient*
Address
________________________________________________
(12) DME-Purchase
(56) Ground Transportation
(AC) Targeted Case Management
City/State/Zip
____________________________________________
(18) DME-Rental
(57) Air Transportation
(AD) Occupational Therapy
Ambulance Transport Code _________________________________
(35) Dental Care
(69) Maternity
(AE) Physical Therapy
(42) Home Health Care
(72) Inhalation Therapy
(AF) Speech Therapy
Ambulance Transport Reason Code
__________________________
(44) Home Health Visits
(74) Private Duty Nursing
(AL) Vision-Optometry
DME Equipment: _______________ New _______________ Us
ed
DA TES OF SERVICE
Line
START
STOP
PLACE OF
PROCEDURE
MODIFIER 1
UNITS
COST/
Item
CCYYMMDD
CCYYMMDD
SERVICE
CODE*
DOLLARS
___________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________
Clinical Statement: (Include Prognosis and Rehabilit ation Potential) A current plan of treatment and progress notes, as to the necessity, effectiveness and
goals of therapy services (PT , OT, RT, SP, Audiology, Psychotherapy, Oxygen Certifications, Home Health and Transportation) must be att ached.
___________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
* If this P A is for Psychiatric or Inp atient st ay, Procedure Code is not required.
Certification Statement: This is to certify that the requested service, equipment, or supply is medically indicated and is reas
onable and necessary for the
treatment of this patient and that a physician signed order is on file (if applicable). This form and any statement on my lette
rhead attached hereto has been
completed by me, or by my employee and reviewed by me. The foregoing information is true, accurate, and complete, and I unders
tand that any
falsification, omission, or concealment of material fact may subject me to civil or criminal liability .
Signature of Requesting Provider ____________________________________________________
Date _________________________
FORWARD TO:
HP, P.O. Box 244036 Montgomery, Alabama 36124-4032
Form 342
Alabama Medicaid Agency
Revised 2-10-2010

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