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UM Phone 773-338-8093 UM Fax 224-231-0070 3019 W. Harrison St. Chicago IL 60612 REQUEST FOR PRIOR AUTHORIZATION FORM Today s Date Patient s Full Name Person completing form Recipient Identification Number RIN Contact information Phone and Fax Number Patient s Date of Birth Facility / Agency / NPI Information Diagnosis/ Diagnoses include ICD-10 codes Referring PCP Rendering Specialist PCP contact information Date of procedure/ admit/ test Procedure/ surgery/ DME requested CPT ICD-10 HCPCS...
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