[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-288482-105":53,"doc-detail-288482-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","eligibilitypreauthorization-request-form-medical-recordsdocumentation-requirements","Eligibility/PreAuthorization Request Form - Medical Records/Documentation Requirements","","Eligibility and pre-authorization request form collecting required member and clinical details for service review. Include all requested information plus associated medical records and clinical documentation for the requested service and diagnosis. Processing takes 48–72 hours after all required information and/or records are received. Only dictated or typed documentation is accepted; handwritten notes are not. The form gathers review type, urgency rationale, prior case information, treating physician, facility and contacts, dates, member identifiers, requested CPTs, associated ICD-10 codes, and comments.",{"@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/eligibilitypreauthorization-request-form-medical-recordsdocumentation-requirements/288482/",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/eligibilitypreauthorization-request-form-medical-recordsdocumentation-requirements/288482.png","ImageObject",442,249,{"name":88,"@type":89},"Terk","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information must be included for an eligibility or pre-authorization review?","Question",{"text":108,"@type":109},"Include all requested information and any medical records/clinical documentation associated with the requested service and diagnosis.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How long does it take to process Eligibility/PreAuthorization Requests after receiving all required materials?",{"text":113,"@type":109},"Processing takes 48–72 hours once all required information and/or records are received.",{"name":115,"@type":106,"acceptedAnswer":116},"Are handwritten notes accepted on the documentation?",{"text":117,"@type":109},"No. Only dictated/typed documentation will be accepted; handwritten notes are not accepted.","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},288482,1790049760,{"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":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"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":139,"read_time":4},1099525198933,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Fax number: 737-402-7752  \n[Eligibility@altruahealthshare.org](Eligibility@altruahealthshare.org)  \n[1-888-244-3839](1-888-244-3839)  \n[www.altrualhealthshare.org](www.altrualhealthshare.org)  \nPlease include all information requested as well as any medical records/clinical documentation that is associated with requested service and diagnosis to be considered for review.  \nPlease allow 48-72 hours to process Eligibility/PreAuthorization Requests once all required information and/or records are received.  \n** Only dictated/typed documentation will be accepted, no handwritten notes will be accepted.  \nTo: Eligibility Dept  \nNumber of Pages (including Cover Sheet):  \nReview Type:  \nUrgent, Non-urgent, clinical reason for Urgency:  \nInitial request, Extension/renewal/amendment,  \n[Prev. case.\\#:](Prev. case.#:)[ ](Prev. case.#:)Treating physician:  \nPhone: Fax:  \nFacility name:  \nPhone: Fax:  \nContact Name:  \nTitle: Department:  \nContact Phone:  \nContact Fax:  \nDate of Request:  \nAnticipated DOS:  \nMember Name:  \nMember ID:  \nMember DOB:  \nRequested CPT(s):  \nAssociated ICD-10(s):  \nComments:  \n\n|  |  |\n| --- | --- |\n|  |  |\n\n[EMAIL](EMAIL eligibility@altruahealthshare.org | FAX 737.402.7752 | MAIL P.O. Box 90849 | Austin)[ eligibility@altruahealthshare.org |](EMAIL eligibility@altruahealthshare.org | FAX 737.402.7752 | MAIL P.O. Box 90849 | Austin)[ FAX](EMAIL eligibility@altruahealthshare.org | FAX 737.402.7752 | MAIL P.O. Box 90849 | Austin)[ 737.402.7752 |](EMAIL eligibility@altruahealthshare.org | FAX 737.402.7752 | MAIL P.O. Box 90849 | Austin)[ MAIL](EMAIL eligibility@altruahealthshare.org | FAX 737.402.7752 | MAIL P.O. Box 90849 | Austin)[ P.O. Box 90849 |](EMAIL eligibility@altruahealthshare.org | FAX 737.402.7752 | MAIL P.O. Box 90849 | Austin)[ Austin](EMAIL eligibility@altruahealthshare.org | FAX 737.402.7752 | MAIL P.O. Box 90849 | Austin), TX 78709–0849  Altrua Ministries (dba Altrua HealthShare) is NOT an insurance company nor is the membership offered through an insurance company, and the organization is not subject to the regulatory requirements or consumer protections of any state insurance code. Members are self-pay patients. Altrua Ministries is a 501(c)(3) nonprofit corporation.","cbCaij7ghGsw3Ja3","https://ap.wps.com/l/cbCaij7ghGsw3Ja3","pdf",408113,"English","# Request Instructions\n## Submission Requirements\n## Processing Time\n# Form Fields\n## Review Details\n## Provider and Facility Information\n## Member and Clinical Data\n## Dates and Notes","[{\"question\":\"What information must be included for an eligibility or pre-authorization review?\",\"answer\":\"Include all requested information and any medical records/clinical documentation associated with the requested service and diagnosis.\"},{\"question\":\"How long does it take to process Eligibility/PreAuthorization Requests after receiving all required materials?\",\"answer\":\"Processing takes 48–72 hours once all required information and/or records are received.\"},{\"question\":\"Are handwritten notes accepted on the documentation?\",\"answer\":\"No. Only dictated/typed documentation will be accepted; handwritten notes are not accepted.\"}]","Eligibility/PreAuthorization Request Form - Medical Records/Documentation Requirements | PDF",1789633533]