1. MULTI-SPECIALTY CLINIC
AUTHORIZATION REQUEST
Date Received: All documents in this process should be copies.
Originals are for Medical Records
Last Name First Name DOB
Insurance Company Name Ins ID No.
Telephone No Fax No.
Physician Name Physician Specialty
Physician NPI No
Procedure Codes & Description
Diagnosis Codes & Description
SUBMITTED TO INSURANCE FOR AUTHORIZATION:
Date/Time: Your Initials:
Method (circle one) Fax Online Telephone
Submitted Date, time & description of further information requested:
Send copy of this form
to Medical Records
when completed.
Revised 10/14/2014
Medical Record
Docs Needed
(Must be within a year)
Labs
Radiology Reports
Physical Therapy- Proof
Medications
Other -
AUTHORIZATION NUMBER:
Valid Dates
Name of person at Ins. Co.
Date/ Time Your Initials: ________________
SURGERY OR APPT SCHEDULED FOR:
Date: Time: Initials:
