Prior Authorization Form
Patient Name
*
First Name
Last Name
Troy Medicare Member ID
*
Number in the format of 1000XXXX
Type of Service Requested
*
Please Select
Ambulatory / Outpatient Surgery
Diagnostic Radiology
Dialysis
DME Item over $1,000
Home Health visit after initial 30 days
Inpatient Admission
Observation Admission
Clinical Review Updates / Other
Out-of-Network Request
Part B Medication
Outpatient Hospital
SNF
If DME item (Repair or Replacement) please give name of Initial DME provider, brand name of item (with model number if possible) and initial delivery date of item
Documentation
*
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Standard or Expedited
Please Select
Expedited
Standard
Part B Drug Expedited
Part B Drug Standard
Patient DOB
*
-
Month
-
Day
Year
Date
Person Submitting the Request
Contact Name
*
Contact Phone Number
*
Format: (000) 000-0000.
Contact Fax Number
*
Format: (000) 000-0000.
Requesting Provider
Requesting Provider Name
*
Requesting Provider Phone Number
*
Format: (000) 000-0000.
Requesting Provider Contact Fax Number
*
Format: (000) 000-0000.
Requesting Provider NPI
*
Servicing Provider
Servicing Provider Name
*
Servicing Provider Phone Number
*
Format: (000) 000-0000.
Servicing Provider Contact Fax Number
*
Format: (000) 000-0000.
Servicing Provider NPI
*
Servicing Facility Name
*
Servicing Facility Tax ID
*
Servicing Facility NPI
*
Other Info
Inpatient Admit Date OR Surgery Date, if available
-
Month
-
Day
Year
Date
CPT Codes
Please include all CPT Codes
ICD10 Codes
Please include all ICD10 Codes
Date Range for Home Health Visits
Additional Notes
Submit
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