Orthodontic Services Prior Authorization Form

What type of prior authorization is being requested?*

Routine: Applies to routine service requests. These should be submitted at least 15 days ahead of scheduled service. This applies to most requests. Request must be approved before service can be performed.Administratively Urgent (Routine service scheduled prior to the 15 days allowed to review, reserved for filling cancellations)Urgent Urgent means there is imminent risk to the member’s health if service is not received within 72 hours. This box should not be used for scheduling conveniences.
GHC-SCW Care Management reserves the right to change referral type should the request not match definitions listed above.
Patient Information
Patient's Member Number:*
Patient's Name: *
Full Name
Patient's Date of Birth *

MonthDayYear
Date
Patient's Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Referred by Provider
Referring Provider's Name *
Full Name
Referring Provider's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Referring Provider's NPI #:*
Prior Authorization Form Submitted By:*
Full Name
Referring Provider Phone #:*
Please enter a valid phone number.
Referring Provider Fax #:*
Please enter a valid fax number.
Patient's Request

YesNo
REFERRED TO FACILITY/PROVIDER
Facility Name:*
Facility Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Facility NPI ID #: *
Facility Phone #:*
Please enter a valid phone number.
Facility Fax #:*
Please enter a valid fax number.
Facility Tax ID:*
Services Requested and Diagnosis Information

Supporting clinical documentation must accompany this request.
What services are being requested for this prior authorization?*

Consult OnlyDME (Durable Medical Equipment)Inpatient ServicesOutpatient Surgical ServicesMRI/PET/CTInfusion/InjectableHome Care/HospiceInpatient SNFLabDiagnosticsOther
Diagnosis Information *

Diagnosis Code

Diagnosis Description

Procedure CodeState / Province

Procedure Description
Please fill out and upload the Orthodontic Services Evaluation form to accompany this request (required):
Cancelof
Number Of Visits:*
Frequency of Visits:*
Date(s) Of Service:*
Month/Day/Year
Comments:
A referral is not a guarantee of eligibility or benefits under the member’s health plan. Payment will be made in accordance with the member’s plan benefits at the time the service is rendered. Please call Member Services at (800) 605-4327 if you have questions about benefits. Retrospective requests will not be accepted.

Prior Authorization and Clinical Information Fax Number: (608) 831-6099
Should be Empty:

GHC-SCW Care Management reserves the right to change referral type should the request not match definitions listed above.

Patient Information

Referred by Provider

REFERRED TO FACILITY/PROVIDER

Services Requested and Diagnosis Information