If you are covered under Coventry Healthcare, there is a new form that you will need to fill out. This form is called the Prior Authorization Request Form and it is used to request prior authorization for certain services. Services that may require prior authorization include hospitalization, outpatient services, and prescription drugs. You can find more information about the Prior Authorization Request Form on Coventry's website. Make sure to submit your form as soon as possible to avoid any delays in getting the services you need.
| Question | Answer |
|---|---|
| Form Name | Coventry Healthcare Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | c056957 resident health assessment form ahca 3110 1023 |
Medicare Advantra
Specialty Office
Referrals
PLEASE FAX TO:
Contact Person:__________________________________________________
Phone Number:_____________________Fax Number:__________________
Member Name
Member ID #
Referring Provider –
Name/TIN #
Specialty Provider-
Name/TIN #
Group Practice
Name (if applicable)
Diagnosis
CPT Code
Number of visits requested
The following to be
be completed by completed by GHP CHCMO
Authorization
To Date
From Date
Number of Visits
Approved
CHCMOGHP Initials/Dateinitials/Date
Total form completion is required. Partially completed forms will be returned to the “Referring Provider” for completion
Confirmation form will be faxed to “Referring Provider”