Altamed is a healthcare company that provides high-quality and affordable medical services to individuals and families in the Los Angeles area. If you're looking for a reliable and affordable health care provider, Altamed is definitely worth checking out. They have a variety of different services available, so you're sure to find one that meets your needs. Plus, their staff is friendly and knowledgeable, which makes the experience even better. So if you're in need of some medical care, be sure to check out Altamed!
| Question | Answer |
|---|---|
| Form Name | Form Altamed |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | altamed form, altamed auth form, altamed referral form, altamed doctors note |
ALTAMED AUTHORIZATION REQUEST FORM
URGENT (72 HOURS) Requests submitted as an urgent referral when standard timeframes could seriously jeopardize the Member's life or health or ability to attain, maintain or regain maximum function.
ROUTINE (5 BUSINESS DAYS)
REQUEST DATE: _________________
SUBMIT AUTHORIZATION REQUEST VIA FAX TO
PATIENT INFORMATION
Patient Name: |
DOB: |
|
|
Health Plan: |
Health Plan ID: |
AUTHORIZATION REQUEST INFORMATION
REQUESTED PROVIDER:
Provider Name:
Provider Specialty:
SERVICES REQUESTED:
CPT Code:
CPT Code Description:
Ambulatory
Surgery
Center/Hospital
Name:
Place of Service:
TREATMENT AND
ATTACHMENTS: Progress Notes |
Laboratory & Radiology Findings |
Medication List |
Other |
Referring Physician Name: __________________________________________________________________________________
Referring Physician Address: __________________________________________________________________________________
Referring Physician Phone: ______________________________ Referring Physician Fax: _____________________________
Office Contact Name: ______________________________
Primary Care Physician (If different than referring Provider):___________________________________
**For Inquiries or questions on authorization status or in general call the AltaMed Customer Service Department at: (866)