[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283902-105":3,"doc-detail-283902-en":81,"detail-sidebar-cat-1-en-105":97},{"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","prior-authorization-request-form-carecontinuum","Prior Authorization Request Form - CARECONTINUUM","","Prior Authorization Request Form for CARECONTINUUM home health and/or home infusion services, including MDO or AIC services. The form collects urgency, patient identification and demographics, billing provider details, prescriber information, requested drug data (type, name, codes, dose, frequency, route, start/end dates), diagnosis and ICD-10-CM codes, patient measurements, therapy status, place of service, and treatment direction. It also requests medical necessity narrative and supporting documentation selections to support review.",{"@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/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/prior-authorization-request-form-carecontinuum/283902/",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/prior-authorization-request-form-carecontinuum/283902.png","ImageObject",442,249,{"name":42,"@type":43},"Aurora","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-25","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",8,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information is required from the patient section of the form?","Question",{"text":63,"@type":64},"The form requests member identification, patient name, date of birth, street address, city/state/zip, and primary/alternate phone numbers.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What does the clinic information section ask for?",{"text":68,"@type":64},"It asks whether the billing provider is the same as the prescriber, the clinic name, required NPI, and prescriber/office contact details including phone, fax, and email.",{"name":70,"@type":61,"acceptedAnswer":71},"What details are needed for the requested drug information and medical necessity?",{"text":72,"@type":64},"It requires request type, drug name, J code and HCPCS code, dose, frequency, route, start and end dates, diagnosis and ICD-10-CM codes, patient weight/height, therapy status, place of service, direction, and a medical necessity statement plus selected documentation for review.","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},283902,1790696664,{"code":4,"msg":82,"data":83},"success",{"doc_id":79,"user_id":84,"nickname":42,"user_avatar":85,"doc_module":22,"category_id":86,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":87,"file_id":88,"file_url":89,"file_type":90,"file_size":91,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":92,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":93,"faqs":94,"seo_title":95,"seo_description":12,"update_tm":96,"read_time":22},4810365810221,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d",17,"Prior Authorization Request Form  \nCARECONTINUUM is contracted to provide pre‐certification and authorization of home health and/or home infusion services, MDO or AIC services. Certain requests for coverage require review with the prescribing physician. Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process.  \nUrgency (select one): YES NO  \n\n| Patient Information |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Member Identification Number |  |  | Group Number |  |  |\n| Patient Name (Last, First) |  |  |  |  | Date of Birth (mm/dd/yyyy) |\n| Street Address |  |  |  |  |  |\n| City |  | State |  |  | Zip code |\n| Primary Phone Number |  |  | Alternate Phone Number (if available) |  |  |\n| Clinic Information |  |  |  |  |  |\n| Is the billing provider the same YES NO\u003Cbr>as the prescriber? (select one) |  |  |  |  |  |\n| Clinic Name (required) |  |  |  | NPI Number (required) |  |\n| Office Contact (if available) |  |  |  | Office Contact Phone Number |  |\n| Street Address |  |  |  |  |  |\n| City |  | State |  |  | Zip Code |\n| Phone Number | Fax Number |  |  | Email Address |  |\n| Prescriber Information |  |  |  |  |  |\n| Prescriber Name (Last, First) |  |  |  | NPI or DEA Number |  |\n| Office Contact (if available) |  |  |  | Office Contact Phone Number |  |\n| Street Address |  |  |  |  |  |\n| City |  | State |  |  | Zip Code |\n| Phone Number | Fax Number |  |  | Email Address |  |\n| Prescriber Signature |  |  |  |  |  |\n\nPrior Authorization Request Form  \nCARECONTINUUM is contracted to provide pre‐certification and authorization of home health and/or home infusion services, MDO or AIC services. Certain requests for coverage require review with the prescribing physician. Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process.  \nMember ID Number: Patient Name:  \n\n| Requested Drug Information |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Request Type (select one): New Request Renewal of Previous Approval |  |  |  |  |\n| Drug Name |  |  | J Code | HCPCS Code |\n| Dose |  | Frequency |  | Route |\n| Start Date |  |  | End Date |  |\n| Diagnosis |  |  |  |  |\n| ICD‐10 CM Diagnosis Code(s) |  |  |  |  |\n| Patient Weight | Patient Height |  | Patient currently established YES NO\u003Cbr>on therapy (select one) |  |\n| Place of Service Home Physician’s Office Hospital Outpatient Ambulatory Fusion Suite (select one) |  |  |  |  |\n| Direction: |  |  |  |  |\n| Medical Necessity (clinical and treatment history) . Include medications, adverse effects and conditions. |  |  |  |  |\n| The following documentation is enclosed for review if the prior approval request (please select):\u003Cbr>Office Notes Medical Records Other ‐ Describe |  |  |  |  |","cbCaivH2XKaBLvUp","https://ap.wps.com/l/cbCaivH2XKaBLvUp","pdf",747631,"English","# Prior Authorization Request Form\n## Patient Information\n## Clinic Information\n## Prescriber Information\n## Requested Drug Information","[{\"question\":\"What information is required from the patient section of the form?\",\"answer\":\"The form requests member identification, patient name, date of birth, street address, city/state/zip, and primary/alternate phone numbers.\"},{\"question\":\"What does the clinic information section ask for?\",\"answer\":\"It asks whether the billing provider is the same as the prescriber, the clinic name, required NPI, and prescriber/office contact details including phone, fax, and email.\"},{\"question\":\"What details are needed for the requested drug information and medical necessity?\",\"answer\":\"It requires request type, drug name, J code and HCPCS code, dose, frequency, route, start and end dates, diagnosis and ICD-10-CM codes, patient weight/height, therapy status, place of service, direction, and a medical necessity statement plus selected documentation for review.\"}]","Prior Authorization Request Form - CARECONTINUUM | PDF",1789621756,{"code":4,"msg":82,"data":98},[99,104,109,114,119,124,127,132,137],{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},11,"Presentations",90,"presentations",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},12,"Resumes",80,"resumes",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":111,"show_sort_weight":112,"slug":113},14,"Invoices",70,"invoices",{"id":115,"doc_module":22,"doc_module_name":25,"category_name":116,"show_sort_weight":117,"slug":118},15,"Posters",60,"posters",{"id":120,"doc_module":22,"doc_module_name":25,"category_name":121,"show_sort_weight":122,"slug":123},16,"Social Media",50,"social-media",{"id":86,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":125,"slug":126},40,"forms",{"id":128,"doc_module":22,"doc_module_name":25,"category_name":129,"show_sort_weight":130,"slug":131},18,"Letters",30,"letters",{"id":133,"doc_module":22,"doc_module_name":25,"category_name":134,"show_sort_weight":135,"slug":136},21,"Paper Templates",5,"papers-templates",{"id":138,"doc_module":22,"doc_module_name":25,"category_name":139,"show_sort_weight":4,"slug":140},158,"General","general-158"]