Scott R. Elkin, D.O. Suzanne Grantham, PMHNP Susan Salyer, PMHNP 1510 W. 34th Street, Suite 205 Austin, Texas 78703 Office: 512.306.0061 Fax: 512.306.0069 Email: firstname.lastname@example.org Insurance Authorization Form In an effort to maximize insurance benefits available for your visit we ask that you contact your insurance company to obtain prior authorization for your care with our office. This form must be received by our office at least 48 hours prior to your scheduled appointment in order for us to bill your insurance company for your appointment. If we do not have an authorization on file the day of your appointment it will be necessary to reschedule you for an alternate date. Should you have any questions or need help obtaining an authorization please contact our office. Thank you! Patient Name: ___________________________________________________________ Appointment Date: _______________________________________________________ Insurance Company: ______________________________________________________ Authorization Number: ____________________________________________________ Date Span of Authorization: ________________________________________________ Total Number of Visits Authorized: ___________ □ 90801 X _______ (Initial Evaluation) □ 90805 X _______ (Follow-up 20-30 minutes) □ 90807 X _______ (Follow-up 40-50 minutes) □ 90862 X _______ (Medication Management) When obtaining authorizations Blue Cross Blue Shield patients (unless HMO Blue) should request one (1) 90801 and nine (9) 90862 visits. HMO Blue patients please call our office for additional help and information before contacting your insurance company for an authorization. All other patients should request one (1) 90801, five (5) 90805, and four (4) 90807.