For medical professionals and their administrative staff, having reliable processes in place is essential for effectively managing your practice's authorization requests. When it comes to maintaining the patient-provider relationship, promptly answering auths helps ensure good communication between all involved parties – that’s where a Medical Management Authorization Form can prove beneficial. This post will discuss why you should use one and how to go about creating a successful form for your organization.
| Question | Answer |
|---|---|
| Form Name | Medical Management Authorization Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | medical management authorization, indiana health request form, indiana medical request form, id information iuhmm form |
Indiana University Health Medical Management
Authorization Request Form
Forward completed form via FAX to IUHMM at (317)
**Please complete all fields for review**
REQUESTING PHYSICIAN INFORMATION |
REQUESTING VENDOR INFORMATION |
Ordering MD: ____________________________________ |
Vendor: ________________________________________ |
**TAX ID: ________________________________________ |
**TAX ID: _______________________________________ |
Address: _______________________________________ |
Address: _______________________________________ |
Phone: __________________ Fax: _________________ |
Phone: _________________ Fax: __________________ |
Contact: ________________________________________ |
Contact: ________________________________________ |
|
|
MEMBER INFORMATION
Name: _______________________________________
ID#: _______________________________
DOB: ______/______/______
SS#: ________/________/________
Phone: ______________________________
******IUHMM USE ONLY******
AUTHORIZATION NUMBER________________________
□Services APPROVED As Requested
□Request MODIFIED (see below for detail)
□Request DENIED, Letter To Follow
Modifications Made:______________________________
IUHMM Staff:____________________________________
Date:___________________________________________
Date of Service
CPT or HCPC Code
Requested Service
Place of Service + |
INP |
|
OP |
|
OBS |
Units
Diagnosis / ICD9 Code
CLINICAL SUMMARY (Form will be rejected if CLINICAL SUMMARY is NOT completed). (Send attachments, if needed).
SIGNATURE OF REQUESTING MD: ___________________________________________ DATE: ______________________________