Online Preauthorization Request - Injury Management Organization

If you have a physical copy of the TDI Standard Prior Authorization Request Form for Health Care Services form already filled out, please click here.

Claim Profile
Patient Name*
First Last
Patient Address*
Street Address Address Line 2 City State ZIP Code
Patient Phone*
Claim Number*
Date of Injury (D.O.I)*
MM slash DD slash YYYY
D.O.B.*
MM slash DD slash YYYY
Employer*
Insurance Carrier*
Adjuster Name*
First Last
Employee Network participation*
- 1305 Certified Network
- 504
- None

Treating Provider Information
Treating Provider Name*
Treating Provider Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Treating Provider Phone*
Treating Provider Fax*
Email Address For Determination Letters
Tax ID #
NPI #
Treating Provider Contact Name
First Last

Requesting Provider information

Please include the Requesting Provider’s information who is seeking authorization.
Requesting Provider
- If the Requesting Provider is the same as the Treating Provider, please check box.
Requesting Provider Name
Requesting Provider Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Requesting Provider Phone
Requesting Provider Fax
Email Address For Determination Letters
Tax ID #
NPI #
Requesting Provider Contact Name
First Last

Facility information

Please include the Facility Information where the requested service would be performed.
Facility Name
Facility Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Facility Phone*
Facility Fax*
Email Address For Determination Letters
Tax ID #
NPI #
Facility Contact Name
First Last

Service requested & type of review
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Requested Procedure*
Body Part*
Medication Name, Quantity and # of Refills
In-Patient?*
- Yes
- No
If yes, please provide number of days.
Frequency & Duration
ICD-10 Code(s)
CPT Code(s)
Peer-to-Peer Contact Name *
First Last
If other than requestor
Peer-to-Peer Contact Phone
Specific Peer-to-Peer Date
MM slash DD slash YYYY

When is the best time for an IMO team member to call the Peer-to-Peer contact above?
Time

: Hours

Minutes

AM/PM

Specific Peer to Peer Time

Submissions & Attachments
Contact Email for Confirmation**

Where you would like the confirmation email sent to print or store for your records (all submitted fields included)?
Today's Date*
MM slash DD slash YYYY
Attachments

Please attach supporting clinical records to validate this request.
Deliver records by
- I will attach all records to this form below - Please name files based on the patient's last name.
- I will fax all records to 713.974.1962
Additional comments