PT, OT and SLT Prior Authorization Form

PT, OT and SLT Prior Authorization Form
A prior authorization 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. Failure to obtain Prior Authorization may result in GHC-SCW not providing coverage for the service.
Processing time frame may take up to 15 Calendar Days for a decision to be made.
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
Requesting Provider
Requesting Provider's Name *
Full Name
Prior Authorization Form Submitted By:*
Full Name
Email Address of Person Submitting Prior Authorization Form*
example@example.com
Requesting Provider's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Requesting Provider Phone #:*
Please enter a valid phone number.
Requesting Provider Fax #:
Please enter a valid fax number.
Requesting Provider's NPI #:*
Services To Be Performed At
Facility Name:*
Facility Address:*

Street Address

Street Address Line 2

CityState

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

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

Speech TherapyPhysical TherapyOccupational TherapyTherapy Evaluation Only
Diagnosis Information *

Diagnosis Code

Diagnosis Description

Procedure CodeState / Province

Procedure Description
Please upload all supporting clinical documentation to accompany this request:

Cancelof
Additional Visits Request:
Existing Authorization Number:*
Number Of Visits Approved:*
Number of Visits Used at Time of Request:*
Number of Additional Visits Requested:*
Month/Day/Year
Please include the Plan of Care/Treatment Plan along with treatment notes for consideration.*
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:

PT, OT and SLT Prior Authorization Form

Processing time frame may take up to 15 Calendar Days for a decision to be made.

Patient Information

Requesting Provider

Services To Be Performed At

Services Requested and Diagnosis Information

Additional Visits Request: