Authorization for Visit Company

							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: frontdesk@drelkin.com



               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.