1199 Authorization Form – Fill Out and Use This PDF

1199 Authorization Form - PDF Details and Instructions

The 1199 Authorization Form is a single-page fax form used by ordering physicians and office staff to request prior authorization for radiology imaging studies through the 1199SEIU Benefit Funds. It covers MRI, CT scans, PET scans, and other advanced imaging modalities that require fund approval before the procedure is performed.

The form requires the following information:

• Date of the authorization request and office contact details
• Referring physician name, office address, and preferred callback time
• Patient full name, date of birth, and 1199SEIU member ID
• Health plan or group name
• Requested imaging procedures with CPT codes and ICD-10 diagnosis codes
• Clinical indications and any prior test results supporting medical necessity

The form includes a HIPAA confidentiality notice, confirming it contains protected health information. Unauthorized recipients are directed to contact the sender and return or destroy the fax.