Authorization Request Form by wyi19001

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									                                                        Authorization Request
Fields with asterisks (*) are required

Date:

*Provider Point of Contact Name:                                               Provider Point of Contact Phone:

*Provider Name:                                                                Provider Point of Contact Email:

*Provider ID:

Are multiple appointments required to complete treatment? Yes No

*Referred Services (Please enter at least one service line and include either tooth number or tooth range.)

Procedure:                                                 Tooth Number               Tooth Range

                                                                                      Tooth Surface(s)                      Charge

Procedure:                                                 Tooth Number               Tooth Range

                                                                                      Tooth Surface(s)                      Charge

Procedure:                                                 Tooth Number               Tooth Range

                                                                                      Tooth Surface(s)                      Charge

Procedure:                                                 Tooth Number               Tooth Range

                                                                                      Tooth Surface(s)                      Charge
Attachments? Yes No
Notes:




Appointment Information
*Social Security Number:                                                       *Member Name:

*Date of Birth:                                                                *Member Rank:

*Member Branch of Service:

*Member Address:


Member Email:                                                  Member Phone:                                       *Either email or phone is required

Member Fax:                                                                    Contact Preference:
First Appointment Date & Time:                                                                                                  a.m.    p.m.
Authorizations require 3 to 5 business days for review. Services performed without approval will not be paid. You will be notified of the
authorization outcome.
                                                         For United Concordia use only
   Authorization Number                                       Appointment Control Number
                                                Return to United Concordia by faxing: 1-866-308-4138
                        or mailing: United Concordia Companies, Inc. • ADDP Unit • P.O. Box 69430 • Harrisburg, PA 17106-9430

								
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