General Authorization Form

Member Information
Enter Member Id and Date of Birth to validate Member before proceeding with the form.
Member's ID#*
Member's DOB*
MM slash DD slash YYYY
Date of Service (if known)
MM slash DD slash YYYY
Name*
First Last
Error Message
Facility Information
Hospital/Facility NPI*

10 digits
Hospital/Facility Name*

where procedure will take place
Error Message
Type of request*
Type of request *
- Outpatient
- Inpatient
Ordering MD*
Contact Name*
Contact Phone #*
Contact Fax #*
Email address in order to receive confirmation of request receipt*

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Clinical Information
CPT Code(s) (Click + or - at the right to add more CPT Codes)*
CPT Code Units

Example CPT code: 12345
Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*
Diagnosis ICD 10 Diagnosis Code

Example ICD 10 Diag Code: Z87.890
Description of procedure*
Attach Clinical*
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10.
Upload only PDF or Word Document
Signature of Treating Physician*
Signature Date:*
Request Method*
Request Method *
- Standard
- Expedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.
  Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.
Attach additional Clinical documents for Expedited request*
Accepted file types: pdf, doc, docx, Max. file size: 13 MB.
Upload only PDF or Word Documents
Signature of Physician or Licensed Provider (Required for Expedited request)*
Signature Date:*
Comments
Authorization is not a guarantee of payment
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Member Information

CPT Code	Units

Diagnosis	ICD 10 Diagnosis Code