Phone: (602) 824-3760 Phone: (602) 824-3900 (800) 747-7997

Phone: (602) 824-3760
(800) 747-7997
Phone: (602) 824-3900
(888) 864-1114
PRIOR AUTHORIZATION REQUEST FORM
SELECT WHICH HEALTH PLAN YOU ARE REQUESTING AUTHORIZATION
PHOENIX HEALTH PLAN (AHCCCS) – FAX # (602) 674- 6678
PHOENIX ADVANTAGE - FAX # (602) 674-6627
PHOENIX ADVANTAGE PLUS (SNP) - FAX # (602) 674-6627
PHOENIX ADVANTAGE SELECT - FAX # (602) 674-6627
DATE OF REQUEST:
PHONE: (
)
REQUEST TYPE:
ROUTINE
CONTACT PERSON:
EXT.
FAX# (
)
EXPEDITED(IF SERVICE IS MEDICALLY NECESSARY WITHIN 72 HOURS)
NON-CONTRACTED PROVIDER
NOTE: TO AVOID DELAY OR NEED FOR RESUBMISSION COMPLETE THE FORM IN ITS ENTIRETY AND SUBMIT APPROPRIATE DOCUMENTATION WITH INITIAL REQUEST.
DOCUMENTATION ATTACHED TO SUPPORT REQUEST INCLUDES:
MEMBER NAME:
CLINICAL NOTES
LAB RESULTS
X- RAY REPORTS
MEMBER ID:
DOES MEMBER HAVE OTHER INSURANCE:
YES
OTHER DIAGNOSTIC TESTS
MEMBER DOB:
NO
OTHER INSURANCE INFO:
DIAGNOSIS:
ICD-9 CODE:
NAME OF REQUESTING PROVIDER:
NPI#
ADDRESS (CITY, STATE, ZIP)
REFERRED TO (SERVICING PROVIDER NAME):
ADDRESS (CITY, STATE, ZIP):
Group Affiliation/F#
SPECIALTY TYPE:
NPI#
PHONE#
INITIAL CONSULTATION
FOLLOW-UP VISITS #OF VISITS REQUESTED_________
LOCATION OF SERVICE(S) REQUESTED:
INPATIENT
OUTPATIENT FACILITY
AMBULATORY CARE CENTER
FACILITY NAME:
DATE OF SERVICE:
ADDRESS (CITY, STATE, ZIP):
OFFICE
CPT CODE(S) & QUANTITY (IF APPLICABLE):
SURGERY/PROCEDURE DESCRIPTION:
DME/ORTHOTICS/PROSTHETICS DESCRIPTION:
PHYSICAL THERAPY
COMMENTS:
OCCUPATIONAL THERAPY
RENTAL
PURCHASE
HCPCS CODE(S):
SPEECH THERAPY # OF THERAPY VISITS REQUESTED:
FOR
HEALTH PLAN
USE ONLY
NOTE: APPROVAL IS NOT A GUARANTEE OF PAYMENT. PAYMENT IS LIMITED TO SERVICES SPECIFIED ON THIS FORM AND MEMBER’S ELIGIBILITY AT TIME OF SERVICE.
APPROVED
AUTH EXPIRATION DATE:
DATE:
DENIED
DATE:
REFERENCE NUMBER:
Signature:
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Rev. 11/2013