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Includes instructions to complete all required fields and provide supporting treatment information and medical notes. Collects patient/member demographics and insurance ID, plus referring/requesting provider and rendering/attending provider details. Requests clinical data such as service type, diagnosis and diagnosis codes, proposed dates, facility, inpatient days or outpatient visits, procedures/tests with CPT/HCPCS or revenue codes, and requested DME pricing and rental information. 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If you need more room, you may attach additional pages or forms. Send or fax this information to the member’s health plan in advance of the proposed services. This form and any supporting medical documentation must be faxed or mailed to MVP’s Corporate Utilization Management Department: 625 State Street, Schenectady, NY 12305-Fax 1-800-280-7346 Telephone 1-800-568-0458  \n\n| Patient/Member Information (* Required Field) |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| *First Name: Middle Initial: *Last Name: |  |  |  |  |  |\n| *Health Insurance ID\\#: |  | *DOB (MM/DD/YYYY): / / |  |  | *Gender: Male  Female  Unknown  |\n| *Address: Apt.\\#: |  |  |  |  |  |\n| *City: *State: *Zip: Telephone \\#: |  |  |  |  |  |\n| Referring/Requesting Provider Information |  |  | Rendering/Attending Provider Information |  |  |\n| First Name: Last Name: |  |  | First Name: Last Name: |  |  |\n| NPI/TIN \\#: Specialty: |  |  | NPI/TIN \\#: Specialty: |  |  |\n| Group/Practice Name: |  |  | Group/Practice Name: |  |  |\n| NPI/TIN \\#: |  |  | NPI/TIN \\#: |  |  |\n| Address: Suite \\#: |  |  | Address: Suite \\#: |  |  |\n| City: State: Zip: |  |  | City: State: Zip: |  |  |\n| Office Contact/\u003Cbr>Person Completing Form: |  |  |  |  |  |\n| Telephone \\#: FAX \\#: |  |  |  |  |  |\n| Required Clinical Information (* Required Field) |  |  |  |  |  |\n| *Date of Request: |  |  | Is this request for Out-of-Network services? Yes  No  |  |  |\n| *Type of Service Requested |  |  |  |  |  |\n| Inpatient Care:\u003Cbr>Medical Admit \u003Cbr>Mental Health/Substance Abuse Admit  OB \u003Cbr>Surgery  Oral Surgery  | Outpatient/Office Care:\u003Cbr>Acupuncture \u003Cbr>Chiropractic \u003Cbr>Infusion/Oncology Drugs \u003Cbr>Mental Health/Substance Abuse  |  |  | Therapies:\u003Cbr>Occupational Therapy \u003Cbr>Physical Therapy \u003Cbr>Speech Therapy \u003Cbr>Cardiac Rehab  |  |\n| Testing:\u003Cbr>Diagnostic Imaging \u003Cbr>Diagnostic Medical Test  | Other:\u003Cbr>DME  SNF  Home Health Vision/Glasses  Other  -please specify: |  |  |  |  |\n| *Date Diagnosed: |  |  | *Place of Service:\u003Cbr>Inpatient  Outpatient  Office  Other  -specify: |  |  |\n| *Proposed Date(s) of Service: From:\u003Cbr>To: |  |  | *Facility Where Service Will be Performed: |  |  |\n| *Proposed Number of Inpatient Treatment Days: |  |  | *Proposed Number of Outpatient Treatment Visits: |  |  |\n| *Primary Diagnosis: |  |  | *Primary Diagnosis Code: |  |  |\n| *Secondary Diagnosis: |  |  | *Secondary Diagnosis Code: |  |  |\n| *Name of Proposed Procedure or Test: |  |  | *CPT/HCPCS or Revenue Code: |  |  |\n| *Requested DME: |  |  |  |  |  |\n| *DME CPT/HCPCS Code: |  |  | *Requested DME Duration (Date(s) of Service): |  |  |\n| *DME Purchase Price: $ |  |  | *DME Monthly Rental Price: $ |  |  |\n\nAdditional Clinical Information Attached:  (No. of pages )","cbCairrMYN7c2PZi","https://ap.wps.com/l/cbCairrMYN7c2PZi","pdf",630210,"English","# Patient/Member Information\n# Referring/Requesting Provider and Rendering/Attending Provider Information\n# Required Clinical Information\n## Request and Service Details\n## Diagnosis and Procedure/Test Details\n## DME and Pricing Information","[{\"question\":\"What information must be submitted with the prior authorization request?\",\"answer\":\"Complete all required fields and include additional treatment information and/or medical notes that support the request. Supporting pages or forms may be attached, and the form plus medical documentation must be faxed or mailed in advance of the proposed services.\"},{\"question\":\"Who needs to provide patient and provider information on this form?\",\"answer\":\"The form collects patient/member details such as name, insurance ID, date of birth, gender, and address. It also gathers referring/requesting provider and rendering/attending provider information, including NPI/TIN, specialty, group/practice name, and contact details.\"},{\"question\":\"What clinical details are required for the service request?\",\"answer\":\"Required clinical information includes date of request, whether the request is for out-of-network services, type of service requested, admission or outpatient context, date diagnosed, place of service, proposed service dates and counts, primary and secondary diagnoses with codes, and the proposed procedure/test with CPT/HCPCS or revenue code. Requested DME details, including codes and pricing, are also collected.\"}]","State of Vermont - Uniform Medical Prior Authorization Form - Instructions and Patient/Provider Details | PDF",1789632290]