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AUTHORIZATION REQUEST FORM CALL 1- 800-748-2544 FAX 1 -888-657-7693 Today s Date: Requesting Provider Name: NPI#: Phone #: Fax #: Requesting Provider Address: Member Last Name: Member First Name:
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What is referralauthorization request form?
Referral authorization request form is a document used to request approval for a referral to a specialist or additional services.
Who is required to file referralauthorization request form?
The referring healthcare provider or facility is required to file the referralauthorization request form.
How to fill out referralauthorization request form?
The referralauthorization request form must be filled out with the patient's information, reason for referral, and any relevant medical history.
What is the purpose of referralauthorization request form?
The purpose of referralauthorization request form is to ensure proper authorization for a patient's referral to a specialist or additional services.
What information must be reported on referralauthorization request form?
The referralauthorization request form must include the patient's name, date of birth, insurance information, reason for referral, and referring provider's information.
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