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It requires confirming eligibility with the health plan within two business days before providing services, and may require documented proof of verification for payment. The form captures provider and facility details, service type selection (office, inpatient, outpatient, ambulatory surgery, labs), requested services, preservice or retroactive timing, and procedure and diagnosis codes, then instructs submission to the Hoag Clinic Utilization Management Team.",{"@graph":63,"@context":119},[64,80,102],{"@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/treatment-authorization-form/288811/",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/treatment-authorization-form/288811.png","ImageObject",442,249,{"name":88,"@type":89},"Bill Black","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-11","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",9,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What is the eligibility verification requirement before providing the service?","Question",{"text":109,"@type":110},"Eligibility must be confirmed with the health plan within two business days prior to providing the service. Proof of verification may be required for payment.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How should providers submit and track prior authorization requests?",{"text":114,"@type":110},"Providers are encouraged to use the EpicCare Link portal to submit and check the status of authorization requests.",{"name":116,"@type":107,"acceptedAnswer":117},"What information is collected in the form for the authorization request?",{"text":118,"@type":110},"The form collects patient information, requesting provider details, requested provider/facility details, selected service type, preservice or retroactive request timing, and CPT/procedure and ICD/diagnosis codes.","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},288811,1791681572,{"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},24189269381491,"https://ap-avatar.wpscdn.com/avatar/160000cf11732dd8392?x-image-process=image/resize,m_fixed,w_180,h_180&k=1788146458752108895","Treatment Authorization  \nForm  \nIf you need access to the referral management system, EpicCare Link, [please visit ](please visit www.hoag.org/hpp for)[www.hoag.org/hpp](please visit www.hoag.org/hpp for)[ for](please visit www.hoag.org/hpp for)[ ](please visit www.hoag.org/hpp for)[EpicCare Link portal sign up and training.](EpicCare Link portal sign up and training.)  \nEligibility must be confirmed with the health plan within 2 business days prior to providing the service. Documented proof of verification of eligibility (i.e., print screen from on-line verification or faxed confirmation from health plan) may be required for payment.  \n\n| PATIENT INFORMATION |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| PATIENT’S FIRST & LAST NAME: |  |  |  |  | DATE OF BIRTH: |  |\n| EPIC MRN (IF APPLICABLE): |  |  |  |  | PHONE: |  |\n| PATIENT’S ADDRESS, CITY, ZIP: |  |  |  |  |  |  |\n| HEALTH PLAN: |  |  | MEMBER ID\\#: |  | MEMBER EFFECTIVE DATE (IF KNOWN): |  |\n| IS PRESENT PROBLEM DUE TO: ☐ ACCIDENT AT WORK ☐ AUTO ACCIDENT IF SO, DATE OF INJURY: |  |  |  |  |  |  |\n| REQUEST FROM |  |  |  |  |  |  |\n| REQUESTING PROVIDER’S NAME: |  |  |  | REQUESTING PROVIDER SIGNATURE: |  |  |\n| REQUESTING PROVIDER’S ADDRESS, CITY, STATE, ZIP: |  |  |  | REQUESTING PROVIDER PHONE NUMBER:\u003Cbr>REQUESTING PROVIDER NPI: |  |  |\n| REQUEST TO |  |  |  |  |  |  |\n| REQUESTED PROVIDER NAME AND/OR FACILITY:\u003Cbr>SPECIALTY: |  |  |  | REQUESTED PROVIDER/FACILITY NPI: |  |  |\n| REQUESTED PROVIDER/FACILITY ADDRESS, CITY, STATE, ZIP: |  |  |  | REQUESTED PROVIDER/FACILITY PHONE NUMBER: |  |  |\n| REQUESTED FACILITY INFORMATION |  |  |  |  |  |  |\n| ☐ OFFICE VISIT / OFFICE PROCEDURE (11) | ☐ INPATIENT SURGERY (21)\u003Cbr>☐ OUTPATIENT PROCEDURE/SURGERY (22) |  |  | ☐ AMBULATORY SURGICAL CENTER (24)☐ ESRD FACIITY (65) |  | ☐ INDEPENDENT LABORATORY\u003Cbr>(81) |\n| REQUESTED SERVICES |  |  |  |  |  |  |\n| ☐ PRESERVICE |  | ☐ RETROACTIVE REQUEST RETRO DATE(S) OF SERVICE: |  |  |  |  |\n| CPT/PROCEDURE CODES |  | UNITS |  |  | ICD/DIAGNOSIS CODES |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |\n\n\n| Attach this form and send to: Hoag Clinic Utilization Management Team |  |  |\n| --- | --- | --- |\n| PO Box 3499 Costa Mesa, CA 92628 |  |  |\n| Phone Number: (949) 791-3490 | Routine Fax: (949) 791-3491 | Urgent Fax: (949) 791-3492 |\n\nNOTE: In-Network providers are encouraged to use EpicCare Link to submit and check the status of a prior – authorization requests. Providers are expected to attach the necessary clinical records or supporting documentation for this request.","cbCailXO0RE7lvHn","https://ap.wps.com/l/cbCailXO0RE7lvHn","pdf",154796,"English","# Patient Information\n# Request Details\n## Request From\n## Request To\n## Requested Facility Information\n## Requested Services\n# Submission Instructions","[{\"question\":\"What is the eligibility verification requirement before providing the service?\",\"answer\":\"Eligibility must be confirmed with the health plan within two business days prior to providing the service. Proof of verification may be required for payment.\"},{\"question\":\"How should providers submit and track prior authorization requests?\",\"answer\":\"Providers are encouraged to use the EpicCare Link portal to submit and check the status of authorization requests.\"},{\"question\":\"What information is collected in the form for the authorization request?\",\"answer\":\"The form collects patient information, requesting provider details, requested provider/facility details, selected service type, preservice or retroactive request timing, and CPT/procedure and ICD/diagnosis codes.\"}]","Treatment Authorization Form | PDF",1789633984]