Healthfirst Authorization Request

Health First
Out of Network

Prior Authorization Request Form

Fax to: 646-313-4603
Member Information
Name

First NameLast Name
Member ID
DOB

MonthDayYear
Date
Provider Information
You are the: Servicing Provider
Name

First NameLast Name
Tax ID
NPI #
Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Email
example@example.com
Contact Person
Phone
Please enter a valid phone number.
Fax
Please enter a valid phone number.
You are the

Requesting ProviderServicing Provider
Name

First NameLast Name
Tax ID
NPI #
Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Email
example@example.com
Contact Person
Phone
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Clinical Information
Member Symptoms and Durations
Summary on Clinical Findings
CPT Codes Requested
DX Codes
Service Type Requiring Authorization
Place of Service
Start Date of Service

MonthDayYear
Date
End Date of Service

MonthDayYear
Date
Order Date

MonthDayYear
Date
Quantity Requested
Please attach clinical doumentation to support the request. I.e. clinical notes, lab reults, x-rays etc. Durable Medical Equipment requires a physician signed prescription and letter of medical necessity.

V1:2/17/2021
Should be Empty:

Health First