Prior Authorization Form PDF Details

Having to obtain a prior authorization for medical treatment can be confusing and time consuming; however, it is an essential part of the process that can help ensure that you receive the right treatment at the right price. In this blog post, we'll take a look at what exactly a prior authorization form is and discuss how to go about completing one correctly in order to secure your needed treatments with minimal hassle. We'll also address common questions regarding insurance companies' interpretations of these forms and explore ways to make sure all of your information is up-to-date when applying for coverage under most insurance policies. Ready? Let's get started!

QuestionAnswer
Form NamePrior Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesbanner university family care prior auth form, university family care prior authorization form, university family care prior auth form, banner university family care prior auth

Form Preview Example

BANNER HEALTH NETWORK

REFERRAL/PRIOR AUTHORIZATION FORM

ATTENTION PATIENTS:

THIS IS YOUR REFERRAL FORM. THE SPECIALIST MAY REFUSE TO SEE YOU WITHOUT IT.

Incomplete forms will not be processed and will be returned to sending provider.

Planned Date of Service: ___________________ (Recommend not scheduling until authorization is obtained)

Patient: ____________________________________________________ DOB:____________________________

Patient’s Health Plan: __________________________________________ ID# ____________________________

Requested Provider: ____________________________________________TIN#___________________________

(Full Name)

Specialty:___________________________________________ Out of Network____ Inpt ___Outpt____Office___

Office Contact Name: _____________________________Phone# ________________ Fax# _________________

(Requested Provider Office)

Place of Service:_______________________________________________TIN#____________________________

(Facility Name)

Referring Provider: ______________________________ Phone# _________________ Fax# _________________

(Full Name)

Office Contact Name: _____________________________Phone# ________________ Fax# _________________

(Referring Provider Office)

Requested Action by Specialist (Optional for PCP to Complete):

Consultation: (Please send the patient back for follow-up and treatment)

[ ] Confirm Diagnosis [ ] Advise as to Diagnosis [ ] Suggest Medication or Treatment

Referral: (Please provide PCP with summaries of subsequent visits)

[] Assume management for this particular problem and return patient after conclusion of care. [ ] Assume future management of patient within your area of expertise.

Diagnosis/ICD-9: _______________________________________________________________________________

Treatment/Procedure with CPT/HCPCS codes:_______________________________________________________

Submit Information for request: List units being administered, Notes, labs, x-rays

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Provider Signature

Date

THE FOLLOWING APPLIES ONLY TO “Banner Choice Plus” PATIENTS:

To access your Banner Option Benefit, your Primary Care Physician should refer you to a contracted provider.

To ensure recommended provider is contracted, call Banner Benefits Service Center at 480-684-7070 (within Metro Phoenix area) or at 800-827-2464 or go on the web www.BannerHealthPlans.com

For Banner Use Only:

BHN Prior Authorization Dept Phone: 480-684-7070 Fax: 480-684-7200 (within Metro Phoenix Area) or 800-697-1441

The information contained in this facsimile message is confidential and intended only for the use of the individual(s) named above. If the reader of this message is not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please immediately notify us by telephone and destroy facsimile. Thank you

BHN Referral Form Revised on 7-6-12

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Part no. 1 for submitting banner health network uhc pre authorization form

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Completing segment 2 of banner health network uhc pre authorization form

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