Seaview Authorization Form PDF Details

In today's healthcare landscape, the Seaview Authorization Form plays a pivotal role in facilitating patient care through its meticulous structure designed for urgent or routine referrals. Situated at 1901 N. Solar Drive in Oxnard, California, and supported by a dedicated team reachable via specific phone and fax numbers, this form is an essential tool entrusted to SeaView IPA Provider Services. It demands detailed patient information, including but not limited to the patient's name, sex, date of birth, and the comprehensive member identification details, to streamline the process. Furthermore, it distinctly outlines the requirements for prior authorization requests and/or direct referrals for specialist care, specifically designated for use only by primary care physicians (PCPs). The form navigates through complexities by meticulously requesting information on the health plan, including other insurance, if applicable, and dives deeper into the medical specifics such as ICD-9 and CPT codes, thereby ensuring clarity on the service to be provided. It also emphasizes the importance of a treatment plan, including the frequency and duration requested for chronic or exacerbated acute conditions, thereby allowing over two visits within 60 days with a treatment plan. Notably, the form includes sections for the physician's name and signature, alongside a critical evaluation of whether clinical guidelines were followed, making it a comprehensive document. However, it also serves as a reminder that the issuance of authorization is not an unequivocal guarantee of payment, underscoring the responsibility of charges for non-covered services on the patients and highlighting the form's validity strictly tied to the specified services for 60 days. Moreover, the form embodies confidentiality, safeguarding the information with the backing of Federal and State law, a testament to the judicious handling of sensitive patient data.

QuestionAnswer
Form NameSeaview Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameslos alamitos ipa referral form, medcore ipa referral form, seaview ipa authorization form, seaview ipa prior authorization

Form Preview Example

URGENT

ROUTINE

REFERRAL AUTHORIZATION FORM

SeaView IPA

Provider Services:

(805) 604-3325

1901 N. Solar Drive, Suite 265

Member Services: (805) 988-5188

Oxnard, CA 93030

Fax:

(805) 988-5162

PATIENT INFORMATION

PRIOR AUTHORIZATION REQUEST

AND/OR DIRECT REFERRAL FOR SPECIALIST

 

 

DIRECT REFERRAL (FOR PCP USE ONLY)

SPEC

ONLY

GROUP ONLY

MEDICAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name (Last, First, MI):

 

 

 

 

 

 

Sex

 

DOB:

 

 

 

Co-Pay:

 

 

 

 

 

 

 

 

 

 

M

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

City / ST:

 

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member ID#:

 

Member Phone Number:

 

PCP:

 

 

PCP Fax Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Plan Name:

 

 

Plan Code:

 

 

Other Insurance?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

Service to be provided by:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ICD-9 Code(s): __________

__________

__________

__________

 

Description:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CPT Code(s): __________

__________

__________

__________

 

Specify Proc/Svc:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frequency/Duration Requested: ________________________________________

(Chronic/exacerbated acute conditions can be >2 visits/60 days with treatment plan)

Treatment Plan:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital/Facility:

 

 

 

 

 

 

Expected Date of Admission:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assistant Surgeon:

 

 

 

 

 

 

Inpatient/Outpatient:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____________________________________________

 

____________________________________________

 

________________________

Physician Name (please print)

 

 

 

 

 

Physician Signature

 

 

 

Date

 

Service to be provided by:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ICD-9 Code(s): __________

__________

__________

__________

 

Description:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CPT Code(s): __________

__________

__________

__________

 

 

Specify Proc/Svc:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Studies Completed/Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____________________________________________

 

___________________________________

 

________________________

 

Physician Name (please print)

 

 

 

 

 

 

 

Physician Signature

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

Reason for referral adequately communicated?

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Adequate information received by the time of the patient’s visit?

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clinical guidelines followed?

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[ ] APPROVED

 

 

 

[ ] CANCELLED

 

 

 

[ ] DENIED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATION #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

______________________________________________________________________________________________

 

________________________

 

Signature of Utilization Department

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*NOTICE: This is not a guarantee of payment. Charges for non-covered service or services rendered to patients whose coverage is no longer in effect are the patients responsibility. This authorization is valid only for services specified for 60 days.

**CONFIDENTIAL: Information protected under Federal and State law, and intended only for the use of the individual or entity named. If the reader of this form is not the intended recipient, employer, or agent responsible for delivering it to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited.

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This PDF doc needs some specific details; in order to ensure accuracy and reliability, make sure you consider the following suggestions:

1. For starters, while filling out the medcore ipa referral form, start with the form section with the following blanks:

Simple tips to fill out seaview authorization stage 1

2. Soon after this part is done, go to enter the relevant information in all these - T S I L A I C E P S R O F L A R R, FrequencyDuration Requested, Treatment Plan, HospitalFacility, Assistant Surgeon, Expected Date of Admission, InpatientOutpatient, Physician Name please print, Physician Signature, Date, T S E U Q E R N O I T A Z I R O H, L A R R E F E R T C E R I D, Y L N O E S U P C P R O F, Service to be provided by, and ICD Codes.

seaview authorization conclusion process detailed (part 2)

Be really attentive while filling out Expected Date of Admission and Physician Signature, because this is the part where many people make some mistakes.

3. The next step is typically quite easy, Reason for referral adequately, C E P S, Y L N O, Adequate information received by, Clinical guidelines followed, Yes, Yes, Yes, L A C I D E M, Y L N O P U O R G, APPROVED, CANCELLED, DENIED, AUTHORIZATION, and Signature of Utilization Department - all of these form fields needs to be completed here.

seaview authorization conclusion process described (step 3)

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