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Collects request details such as urgent, routine, or retro timing, patient demographics, health plan identifiers, diagnosis information, CPT codes and quantities, and referral-to provider information with facility and contact data. Includes attachment options, requesting provider and signature fields, submission instructions by fax, and an additional Home Health section with SOC start and service request tables, plus revision dates.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/altura-authorization-request-form/288481/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/altura-authorization-request-form/288481.png","ImageObject",442,249,{"name":88,"@type":89},"Đào","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How should an authorization request be submitted?","Question",{"text":108,"@type":109},"Submit the authorization request via fax to (323) 720-5608. For authorization status inquiries, call the Altura Customer Services Department at (323) 417-7741.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What timing options are available for authorization requests?",{"text":113,"@type":109},"Options include URGENT (72 HOURS), ROUTINE (5 BUSINESS DAYS/14 CALENDAR DAYS), and RETRO (30 CALENDAR DAYS) with retro date of service details.",{"name":115,"@type":106,"acceptedAnswer":116},"What additional information is required for Home Health requests?",{"text":117,"@type":109},"In addition to the main form fields, complete the Home Health section with Initial Start of Care (SOC), last visit date, and a service request table including CPT codes, start/end dates, visit counts, and frequency.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288481,1789633533,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":47,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":9},1374402968488,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","AUTHORIZATION REQUEST FORM  \nRequest Date:  \n__________________________  \n􀁆  \nAltaMed Health Services  \n􀁆  \nOmnicare Medical Group  \n􀁆  \nLaSalle Medical Associates  \n􀁆  \nFamily Choice Medical Group  \n􀁆  \nGolden Physicians Medical Group  \n􀁆 Medi-Cal 􀁆 Commercial 􀁆 Medicare*  \n􀁆 URGENT (72 HOURS) Request submitted as urgent when standard timeframes could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function.  \n􀁆 ROUTINE (5 BUSINESS DAYS/*14 CALENDAR DAYS)  \n􀁆 RETRO (30 CALENDAR DAYS) Request submitted within 30 calendar days from date of service Retro Date of Service:    \n􀁆 Continuity of Care Last Visit Date:   􀁆 Standing Referral 􀁆 Second Opinion  \nSUBMIT AUTHORIZATION REQUEST VIA FAX TO (323) 720-5608  \nFor inquiries or questions on authorization status, or in general, call the Altura Customer Services Department at (323) 417-7741  \nPATIENT INFORMATION  \nPatients Name:   DOB:    \nHealth Plan: Health Plan ID:  \nAUTHORIZATION REQUEST INFORMATION  \nICD-10: ~~ ~~   \nCPT Code: CPT  \nQty:  \nDiagnosis Description:  \nCPT  \nDescription:  \n\n|  |\n| --- |\n|  |\n|  |\n|  |\n|  |\n|  |\n\nReferred To Provider  \nName:   Specialty:    \nPlace of Service  \nFacility:   (POS):    \nAddress:   Telephone:   NPI/Tax ID:   Reason for referral:    \nAttachments:  \n􀁆 Clinical 􀁆 Laboratory & Radiology Findings 􀁆 Medication List 􀁆 Other  \nRequesting Provider Name:    \nAddress:    \nTelephone:   Fax:    \nPrimary Care Provider (If different than Requesting Provider) :    \nRequesting Provider Signature:    \nFor Home Health requests, in addition to the above section, please complete the following page.  \nRevised: 07/09/2024  \nAUTHORIZATION REQUEST FORM  \nRequest Date:  \n__________________________  \nHOME HEALTH SERVICES  \nInitial Start of Care  \n(SOC):   Last Visit Date:    \n\n| Service Request | CPT Codes | Start Date | End Date | \\# of Visits | Frequency (\\# of Visits per Week) |\n| --- | --- | --- | --- | --- | --- |\n| RN |  |  |  |  |  |\n| PT |  |  |  |  |  |\n| OT |  |  |  |  |  |\n| ST |  |  |  |  |  |\n| HHA |  |  |  |  |  |\n| MSW |  |  |  |  |  |\n| Other |  |  |  |  |  |\n\nFor Internal Use Only:  \nRevised: 07/09/2024","cbCaigEd0zamVUF4","https://ap.wps.com/l/cbCaigEd0zamVUF4","pdf",166724,"English","# Authorization Request\n## Request Timing and Submission\n## Patient Information and Authorization Details\n## Referral Provider and Attachments\n## Requesting Provider Signature\n## Home Health Services (Additional Section)","[{\"question\":\"How should an authorization request be submitted?\",\"answer\":\"Submit the authorization request via fax to (323) 720-5608. For authorization status inquiries, call the Altura Customer Services Department at (323) 417-7741.\"},{\"question\":\"What timing options are available for authorization requests?\",\"answer\":\"Options include URGENT (72 HOURS), ROUTINE (5 BUSINESS DAYS/14 CALENDAR DAYS), and RETRO (30 CALENDAR DAYS) with retro date of service details.\"},{\"question\":\"What additional information is required for Home Health requests?\",\"answer\":\"In addition to the main form fields, complete the Home Health section with Initial Start of Care (SOC), last visit date, and a service request table including CPT codes, start/end dates, visit counts, and frequency.\"}]","Altura Authorization Request Form | PDF"]