PRIOR AUTHORIZATION REQUEST

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					     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 caremanagement@lifewiseor.com.

     Facility/Practice Name                                                                                Provider of Service
                                                                                                           Provider Address
     Contact Person                                                                                        Tax ID #
                                                                                                           Telephone
     Phone #
                                                                                                           Fax
     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:
     Date Scheduled:
     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
     Reference #:
                Procedure/CPT                                                      Period of Treatment                                                Screened by / Reviewed by:
                                                      From:                                        To:
                                                      From:                                        To:
                                                      From:                                        To:
     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


     Comments:




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.
Confidentiality Notice: The information contained in this facsimile message is confidential, and intended only for the individual or entity named above. If the reader is not the intended
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.
                                                                                                                                                                      020605 (11-2010)

				
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posted:5/27/2012
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