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It specifies how to submit urgent and standard transplant-related requests, including fax destinations and required physician signature for urgent priority. The form collects member identification details, requesting provider information, servicing provider/facility details, authorization request procedure codes (CPT/HCPCS) with modifiers, diagnosis code (ICD-10), service start/end dates, and total units. It includes an outpatient service type selection list and requires completion of all required fields with supporting clinical documentation.",{"@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/outpatient-authorization-form-rev-04-29-2021/288825/",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/outpatient-authorization-form-rev-04-29-2021/288825.png","ImageObject",442,249,{"name":88,"@type":89},"Stanford","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-08","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"How do I submit this outpatient authorization request?","Question",{"text":108,"@type":109},"Complete the form and fax to 855-678-6981. For transplant requests, fax to 833-550-1337.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What makes an urgent request eligible for priority?",{"text":113,"@type":109},"Urgent requests must be medically necessary and signed by the requesting physician to receive priority, with details provided within 72 hours to avoid complications.",{"name":115,"@type":106,"acceptedAnswer":116},"What happens if required fields or supporting information are missing?",{"text":117,"@type":109},"Incomplete forms will be rejected. Copies of all supporting clinical information are required, and lack of clinical information may result in delayed determination.","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},288825,1791169581,{"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":8,"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},2336477552062,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","OUTPATIENT AUTHORIZATION FORM  \nComplete and Fax to: 855-678-6981  \nTransplant Request Fax to: 833-550-1337  \n Request for additional units. Existing Authorization  Units   Standard requests-Determination within 15 calendar days of receiving all necessary information.  \nI certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 72 Urgent requests- hours to avoid complications and unnecessary sufering or severe pain.  \n* INDICATES REQUIRED FIELD  \nURGENT REQUESTS MUST BE SIGNED BY THE REQUESTING PHYSICIAN TO RECEIVE PRIORITY.  \n* Date of Birth  \nMEMBER INFORMATION   \n* Member ID Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \n* Requesting NPI * Requesting TIN Requesting Provider Contact Name  \nRequesting Provider Name Phone * Fax  \nSERVICING PROVIDER / FACILITY INFORMATION  \n  Same as Requesting Provider  \n*Servicing NPI *Servicing TIN Servicing Provider Contact Name  \nServicing Provider/Facility Name  \nAUTHORIZATION REQUEST  \n*Primary Procedure Code  \n(CPT/HCPCS) (Modifer)  \nAdditional Procedure Code  \nAdditional Procedure Code  \n(CPT/HCPCS)  \nAdditional Procedure Code  \nPhone Fax  \n*Start Date OR Admission Date  \n(Modifer) (MMDDYYYY)  \nEnd Date OR Discharge Date  \n* Diagnosis Code  \n(ICD-10)  \nTotal Units/Visits/Days  \n*0699*  \n(CPT/HCPCS) (Modifer) (CPT/HCPCS) (Modifer) (MMDDYYYY)  \n\n| *OUTPATIENT SERVICE TYPE\u003Cbr>422 Biopharmacy\u003Cbr>712 Cochlear Implants & Surgery\u003Cbr>299 Drug Testing\u003Cbr>922 Experimental and Investigational Services\u003Cbr>205 Genetic Testing & Counseling\u003Cbr>249 Home Health\u003Cbr>390 Hospice Services\u003Cbr>290 Hyperbaric Oxygen Therapy\u003Cbr>211 OB Ultrasound\u003Cbr>410 Observation | (Enter the Service type number in the boxes)  |  |  |\n| --- | --- | --- | --- |\n|  | 997\u003Cbr>210\u003Cbr>794\u003Cbr>171\u003Cbr>202\u003Cbr>147\u003Cbr>201\u003Cbr>993\u003Cbr>209\u003Cbr>724 | Ofce Visit/Consult Orthotics Outpatient Services Outpatient Surgery Pain Management Prosthetics\u003Cbr>Sleep Study Transplant Evaluation Transplant Surgery Transportation | Behavioral Health\u003Cbr>533 BH Applied Behavioral Analysis\u003Cbr>512 BH Community Based Services\u003Cbr>DME\u003Cbr>417 Rental\u003Cbr>120 Purchase\u003Cbr>515 BH Electroconvulsive Therapy (Purchase Price)\u003Cbr>516 BH Intensive Outpatient Therapy\u003Cbr>510 BH Medical Management\u003Cbr>518 BH Mental Health /Chemical Dependency Observation\u003Cbr>519 BH Outpatient Therapy\u003Cbr>530 BH PHP\u003Cbr>520 BH Professional Fees\u003Cbr>522 BH Psychiatric Evaluation\u003Cbr>521 BH Psychological Testing\u003Cbr>|\n\nALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.  \nCOPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.  \nDisclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Beneft and medically necessary with prior authorization as per Plan policy and procedures.  \nConfdentiality: The information contained in this transmission is confdential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the Rev. 04 29 2021  \nintended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document. EF-PAF-0699","cbCairrj51pjrlPz","https://ap.wps.com/l/cbCairrj51pjrlPz","pdf",1458418,"English","# Member Information\n# Requesting Provider Information\n# Servicing Provider / Facility Information\n# Authorization Request\n## Procedure Codes\n## Diagnosis and Service Dates\n# Outpatient Service Type Selection\n# Submission Requirements and Disclaimers","[{\"question\":\"How do I submit this outpatient authorization request?\",\"answer\":\"Complete the form and fax to 855-678-6981. For transplant requests, fax to 833-550-1337.\"},{\"question\":\"What makes an urgent request eligible for priority?\",\"answer\":\"Urgent requests must be medically necessary and signed by the requesting physician to receive priority, with details provided within 72 hours to avoid complications.\"},{\"question\":\"What happens if required fields or supporting information are missing?\",\"answer\":\"Incomplete forms will be rejected. Copies of all supporting clinical information are required, and lack of clinical information may result in delayed determination.\"}]","Outpatient Authorization Form - Rev. 04 29 2021 | PDF",1789634033]