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It captures request urgency and date, member demographics and identifiers, selecting the line of business, and the requesting and servicing provider information. The form includes diagnosis information, a procedure/services table with units, requested service dates, and optional medical-justification comments. 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It also requires the requesting provider and, if needed, the servicing provider details including NPI, addresses, phone, fax, and office contact.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How do I list the requested procedures and services?",{"text":114,"@type":110},"Use the procedure section to enter line number, CPT/HCPCS code (with modifier if applicable), specific services requested, and units of service in days or quantity for each line item.",{"name":116,"@type":107,"acceptedAnswer":117},"What are the submission and coverage notes for authorization?",{"text":118,"@type":110},"Fax the completed form to the listed fax number and include any required medical records or supporting documents. The form notes that authorization does not guarantee payment and payment is subject to the patient’s eligibility, so the ID card should be current before rendering service.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283994,1790063936,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},962075006959,"https://ap-avatar.wpscdn.com/avatar/e0002397efbe92a78e?_k=1776741047341049297","Prior Authorization Request Form  \nFax completed form to 650-829-2079. Please type into PDF form and fill out all fields.  \nREQUEST  \nURGENT  \nROUTINE  \nMark 􀀹 or X  \nToday's Date:   MM-DD-YYYY  \nIs member currently in the hospital? YES NO IF YES, FAX Facesheet to 650-829-2060  \nLINE OF BUSINESS  \nCAREADVANTAGE  \nMEDI-CAL  \nACE  \nHEALTHWORX  \n􀂾 Member Last Name:   First Name, M. I.:   Street Address:   City, State, ZIP:   Phone:   Member ID\\#:   DOB:   Age:    \n􀂾 Requesting Provider:   NPI:   Street Address:   City, State, ZIP:   Phone:   Fax:   Office Contact:    \n􀂾 Servicing Provider (if needed):   NPI:   Phone:   Fax:   Office Contact:    \nPrimary Diagnosis Code:   Description:    \n\n| Line\u003Cbr>No. | Procedure Code (CPT/HCPCS Code/Modifier if applicable) | Specific Services Requested | Units of Service\u003Cbr>(Days/Quantity) |\n| --- | --- | --- | --- |\n| 1 |  |  |  |\n| 2 |  |  |  |\n| 3 |  |  |  |\n| 4 |  |  |  |\n| 5 |  |  |  |\n| 6 |  |  |  |\n| 7 |  |  |  |\n| 8 |  |  |  |\n| 9 |  |  |  |\n| 10 |  |  |  |\n\nRequested Service Dates FROM: MM-DD-YYYY TO: MM-DD-YYYY  \nOptional comments for medical justification. Requesting Provider please attach required medical records/supporting documents.  \n\n|  |\n| --- |\n| INPATIENT ONLY – LTC Required Information (Mark 􀀹 or X):\u003Cbr>Transfer Initial Reauthorization Bed Hold Skilled Nursing ICF-DD Sub-Acute |\n\nTo the best of my knowledge, the above information is true, accurate and complete, and the requested services are medically indicated and necessary to the health of the patient.  \nSignature of Physician or Provider Title Date MM-DD-YYYY  \n801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 ∙ TEL: 650-616-0050 ∙ TTY: 1-800-735-2929  \nFor authorization questions contact HPSM Health Services Ph 650-616-2070 ∙ Fax 650-829-2079 ∙ For Facesheets fax to 650-829-2060  \nNOTE: AUTHORIZATION DOES NOT GUARANTEE PAYMENT. PAYMENT IS SUBJECT TO PATIENT’S ELIGIBILITY. BE SURE THE ID CARD IS CURRENT BEFORE RENDERING SERVICE. Version 5.0 January 2023  \nPRINT FORM","cbCaidQatqzmXwOB","https://ap.wps.com/l/cbCaidQatqzmXwOB","pdf",1134439,"English","# Request\n## Urgency and Dates\n## Member and Provider Information\n# Medical Details\n## Diagnosis and Procedures\n## Requested Service Dates and Justification\n# Inpatient Only (LTC)\n## Required Selection Fields\n# Attestation and Submission","[{\"question\":\"What information is required about the member and providers on this form?\",\"answer\":\"The form requires the member’s last name, first name, address, city/state/ZIP, phone, member ID, DOB, age, and whether the member is currently in the hospital. It also requires the requesting provider and, if needed, the servicing provider details including NPI, addresses, phone, fax, and office contact.\"},{\"question\":\"How do I list the requested procedures and services?\",\"answer\":\"Use the procedure section to enter line number, CPT/HCPCS code (with modifier if applicable), specific services requested, and units of service in days or quantity for each line item.\"},{\"question\":\"What are the submission and coverage notes for authorization?\",\"answer\":\"Fax the completed form to the listed fax number and include any required medical records or supporting documents. The form notes that authorization does not guarantee payment and payment is subject to the patient’s eligibility, so the ID card should be current before rendering service.\"}]","Prior Authorization Request Form - Complete Medical Details | PDF",1789624059]