PRIOR AUTHORIZATION Fax to Care Management:
REQUEST/RESPONSE 1-800-866-4198 or 1-800-297-1064
Phone: 1-800-596-3382, option 3
Request Date: Urgent Request:
For fast service call 1-800-596-3382, option 3 and follow the prompts for Prior Authorization. If the patient’s health may be compromised by
waiting for the standard processing time, please call the number above or mark this document as Urgent.
If emailing the form, first email https://voltage-pp-0000.lifewiseor.com/login and create an email account to log into LifeWise’s secure email site,
then email firstname.lastname@example.org.
Facility/Practice Name Provider of Service
Contact Person Tax ID #
Fax # Contracted Yes No
Member/Patient Name Date of Birth
Employee/Policy Holder Name
Member ID # Suffix #: Group #:
Procedure/CPT Diagnosis ICD-9
Outpatient Inpatient/Name of Facility:
Clinical Information (attach supporting medical records and include presenting symptoms and previous treatment)
Visit www.lifewiseor.com/provider or call Customer Service at 1-800-596-5258, option 2 to check for eligibility and benefit information.
Please fax this completed form to 1-800-866-4198 or 1-800-297-1064
FOR CARE MANAGEMENT USE ONLY
YES-meets medical necessity criteria Modified NO-see Comments Below No Screening Required
Procedure/CPT Period of Treatment Screened by / Reviewed by:
Letter to follow because:
Service(s) Denied/Investigational/Experimental Service(s) /Investigational/Experimental – Physician Review
Service(s) did not meet medical necessity criteria No response to request for additional information
Service(s) not a contract benefit Member not eligible
Note: Eligibility is binding for 5 business days and quoted benefits are binding for 30 days from date of Authorization. Benefits for services received are subject to eligibility requirements
and plan terms and conditions that are in place at the time the services are provided. Unless relevant to this request, please do not send results of any genetic typing, test or analysis,
including ICD-9 codes.
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recipient, or the employee or producer responsible to deliver it to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is
strictly prohibited. If you have received this communication in error, please immediately notify us by telephone at the number listed on this page.