Outpatient Surgery Form Step 1 of 4 25% 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 Provider InformationHospital/Facility NPI* 10 digitsHospital/Facility Name (where procedure will take place)* Error Message Ordering MD* Contact Name* Contact Phone #*Contact Fax #*Email address in order to receive confirmation of request receipt* Clinical InformationCPT Code(s) (Click + or - at the right to add more CPT Codes)*CPT CodeUnits Example CPT code: 12345Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Description of Procedure* Please use the following checklist to ensure the appropriate clinical information is submitted with this request, to allow for timely medical necessity determination Documentation of medical necessity for the requested procedure may include one or all of the following – Please check all that apply* Physician Office Notes Consults and all Other Evaluations Results of Diagnostic Testing Previous Treatment and Outcomes Attach Clinical information* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Upload only PDF or Word DocumentSignature of Treating Physician or Licensed Provider*Reset to re-sign.Signature Date* Request Method*Request Method *StandardExpedited: 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 and Word filesSignature of Physician or Licensed Provider*Reset to re-sign.Signature Date Authorization is not a guarantee of payment CommentsCAPTCHA