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Prior Authorization Request
Please fax to: 1-866-464-0707
Or call 1-888-454-0013, extension 336336
TX Bexar Harris
El Paso
Type of Request
Elective
Expedited Date/Time Rec’d
Member Name
ID# DOB:
PCP/Requesting Provider
Office Contact Person
Phone#:
Fax#
e-mail:
Referring To:
Specialty/Facility:
Service Requested
ASC
Out-Patient Hospital
In -Patient
Office Procedure
DME
Home Health
PT/OT/ST
Medications
Type of Service
Medical
Surgical
Service Description
Procedure Description
Date of Procedure:
Participating Provider/Facility:
Non-Participating Provider/Facility:
Reason if requesting non par
facility/Provider:
Diagnosis Codes:
Procedure Codes:
Suppporting Clinical Information Attached? Yes
No
(If no, was additional Information requested ?) Yes
No
Date Requested:
Comments:
For Office Use
Pre Cert Specialist
Medical Director Determination:
Certified
Not Certified
Medical Director
Date