[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-288828-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-288828-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","authorization-fax-form-medical-records-request-details","Authorization Fax Form - Medical Records & Request Details","","Authorization fax form for non-urgent requests, requiring submission of the completed document together with supporting medical records, imaging, and test information. The form instructs applicants to add explanations in the comment section if inconsistencies exist with medical office records, and notes that missing relevant details may delay determination. It captures patient and provider demographics, plan identifiers, clinician contact information, CPT/ICD-10 coding, and visit timing. Confidentiality notice emphasizes strict HIPAA-protected use by the named recipient.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/letters/","Letters",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/authorization-fax-form-medical-records-request-details/288828/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/authorization-fax-form-medical-records-request-details/288828.png","ImageObject",442,249,{"name":42,"@type":43},"eBook King","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-11","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",9,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"When should this authorization fax form be used and what additional documents are required?","Question",{"text":63,"@type":64},"Use it for non-urgent requests. Fax the completed form along with medical records, imaging, and tests, and include any required documentation such as exam narratives, office notes, and diagnostic results.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How are urgent (same-day) requests handled?",{"text":68,"@type":64},"Urgent (same day) requests must be submitted by phone rather than using fax submission.",{"name":70,"@type":61,"acceptedAnswer":71},"What confidentiality obligations apply to information sent with this fax?",{"text":72,"@type":64},"The transmission and attachments may contain HIPAA-protected confidential or privileged information intended only for the named recipient. Disclosure, copying, distribution, or use by others is strictly prohibited, and an erroneous receipt requires notification and destruction of the original materials.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},288828,1790179326,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,114,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":111,"show_sort_weight":112,"slug":113},17,"Forms",40,"forms",{"id":115,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":116,"slug":117},18,30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":115,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":22},962088006270,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Authorization Fax Form  \nFor NON-URGENT requests, please fax this completed document along with medical records, imaging, tests, etc. If there are any inconsistencies with the medical office records, please elaborate in the comment section. Failure to provide all relevant information may delay the determination. Phone and fax numbers can be found on  \n[eviCore.com](eviCore.com) under the Guidelines and Fax Forms section. You may also log into the provider portal located on the site to submit an authorization request. URGENT (same day) REQUESTS MUST BE SUBMITTED BY PHONE.  \n| | First Name: |  | Middle Initial: | Last Name: |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n|  | DOB (mm/dd/yyyy ): |  |  | Gender: Male Female |  |  |\n|  | Street Address: |  |  |  | Apt \\#: |  |\n|  | City: |  |  | State: | Zip: |  |\n|  | Home Phone: |  | Cell Phone: |  | Primary Contact: Home Cell |  |\n|  | Health Plan: |  | Member ID: |  | Group ID: |  |\n| | First Name: |  |  | Last Name: |  |  |\n|  | Primary Specialty: |  | TIN: |  | NPI: |  |\n|  | Physician Phone: |  |  | Physician Fax: |  |  |\n|  | Address: |  |  |  | Suite \\#: |  |\n|  | City: |  |  | State: | Zip: |  |\n|  | Office Contact: |  |  |  |  | Ext: |\n|  | Contact Email: |  |  |  |  |  |\n| | First Name: |  |  | Last Name: |  |  |\n|  | Group/Site Name: |  |  |  |  |  |\n|  | Primary Specialty: |  | TIN: |  | NPI: |  |\n|  | Site Phone: |  |  | Site Fax: |  |  |\n|  | Address: |  |  |  | Suite \\#: |  |\n|  | City: |  |  | State: | Zip: |  |\n| | List all applicable CPT codes and modifiers: |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n| | Diagnosis , if known or rule out: |  |  |  |  |  |\n|  | ICD-10 Codes: |  |  |  |  |  |\n|  | Date of last visit: |  |  |  |  |  |\n\nCONFIDENTIALITY NOTICE: This fax transmission, and any documents attached to it may contain confidential or privileged information subject to privacy regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) . This information is intended only for the use of the recipient (s) named above. If you are not the intended recipient , or a person responsible for delivering it to the intended recipient , you are hereby notified that any disclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you have received this transmission in error, please immediately notify eviCore healthcare and destroy the original transmission and its attachments without saving them in any manner.  \nPage 1 of 2  \n\n| C l in ica l Informat ion |  | 1. What is the requested site of service? |\n| --- | --- | --- |\n|  |  | Inpatient Office\u003Cbr>Outpatient Home\u003Cbr>Observation |\n|  |  | 2. What is the anticipated date of service? |\n|  |  | Medical documentation, including an exam narrative, office notes, results of diagnostic tests, and any equivalent notes must be submitted with this form. Additional information/comments: |\n|  |  |  |\n\nPage 2 of 2","cbCaitImbnoKTAxk","https://ap.wps.com/l/cbCaitImbnoKTAxk","pdf",294974,"English","# Authorization Instructions\n# Patient and Provider Information\n## Patient Demographics\n## Provider Details\n## Billing and Diagnosis Codes\n# Clinical Information\n## Site of Service and Date of Service\n## Documentation Submission\n# Confidentiality Notice","[{\"question\":\"When should this authorization fax form be used and what additional documents are required?\",\"answer\":\"Use it for non-urgent requests. Fax the completed form along with medical records, imaging, and tests, and include any required documentation such as exam narratives, office notes, and diagnostic results.\"},{\"question\":\"How are urgent (same-day) requests handled?\",\"answer\":\"Urgent (same day) requests must be submitted by phone rather than using fax submission.\"},{\"question\":\"What confidentiality obligations apply to information sent with this fax?\",\"answer\":\"The transmission and attachments may contain HIPAA-protected confidential or privileged information intended only for the named recipient. Disclosure, copying, distribution, or use by others is strictly prohibited, and an erroneous receipt requires notification and destruction of the original materials.\"}]","Authorization Fax Form - Medical Records & Request Details | PDF",1789634042]