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Online Preauthorization Request
Online Preauthorization Request
MedingenuityAdmin
2020-04-27T18:10:20+00:00
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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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
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
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