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Prior Authorization Request Form
Speech Therapy (ST)/Physical Therapy (PT)/Occupational Therapy (OT)
PROVIDER INFORMATIONGroup Provider Name:
Individual Provider Name:
Date Submitted:Resource
Participating
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What is prior authorization request?
A prior authorization request is a formal process used by health insurance companies to determine if they will cover a prescribed medication, procedure, or service before it is provided to the patient.
Who is required to file prior authorization request?
Typically, healthcare providers such as doctors, specialists, or hospitals are required to file a prior authorization request on behalf of the patient.
How to fill out prior authorization request?
To fill out a prior authorization request, you will need to complete a standardized form provided by the insurance company, which usually includes patient information, details about the treatment or medication, medical necessity, and supporting documentation.
What is the purpose of prior authorization request?
The purpose of a prior authorization request is to ensure that the treatment or medication prescribed is medically necessary and to manage healthcare costs by requiring approval before services are rendered.
What information must be reported on prior authorization request?
The information that must be reported typically includes patient demographics, insurance information, the specific service or medication requested, medical history, diagnosis, and rationale for the request.
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