The 1199 Authorization Form is a document used to authorize the release of confidential or sensitive information. The form must be completed and signed by the individual who has authority to disclose the information. The form can be used for a variety of purposes, such as authorizing the disclosure of patient PHI to another healthcare provider, disclosing employee salary information, or releasing credit card information. Completed forms should be kept in a secure location for future reference.
| Question | Answer |
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| Form Name | 1199 Authorization Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | ICD-9, severity, CPT, IMAGING |
Prior Authorization Request Form
Fax this request form to
1199SEIU Benefit Funds Radiology Review at
(877)
(Please print clearly)
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Date request received: |
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Date request submitted: |
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Office contact person: |
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Referring physician |
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(First/Last name): |
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Physician specialty: |
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Physician phone #: |
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Physician fax: |
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Facility and location for |
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procedure: |
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MVA (No Fault) |
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Patient’s name: |
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Date of birth: |
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Health plan/group name: |
1199SEIU |
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Patient phone #: |
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Member ID#:
State:
List procedure(s) ordered
Procedures
CPT code if available
Clinical indications (e.g., signs, symptoms with severity and duration, working diagnosis) for the ordered exams
THIS SECTION MAY BE ACCOMPANIED OR REPLACED BY A COPY OF MEDICAL NOTES AND/OR REPORTS OF RELEVANT IMAGING AND LAB STUDIES SUPPORTING THE MEDICAL NECESSITY FOR THE STUDY REQUESTED.
Any relevant prior tests, treatments or other information
If our Physician Reviewer needs to contact the ordering physician, what is the best day, time and phone number?
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Phone: |
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Requested |
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Submission |
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by (print): |
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date: |
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Signature:
This fax contains privileged and confidential information intended only for the use of the specific individual or entity named above. If you or your employer is
not the intended recipient of this facsimile (or agent responsible for delivering it to the intended recipient), you are hereby notified that any unauthorized distribution or copying of this facsimile or the information contained in it is strictly prohibited. If you have received this facsimile in error, please notify the person named above by phone and return the original facsimile to the above address via the U.S. Postal Service.
Rev.