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Get And Sign Hmsa Quest Prior Authorization Form 2013-2021

Shown) ( calcium) Quantity Frequency Route of Administration Strength Expected Length of Therapy Patient Information Patient Name: Patient ID: Patient Group No.: Patient DOB: Patient Phone: Prescribing Physician Physician Name: Physician Phone: Physician Fax: Physician Address: City, State, Zip: Diagnosis: ICD Code: Comments: Please circle the appropriate answer for each question. 1. 2. 3. 4. 5. Does the patient have a clinical diagnosis of alcohol Y N dependence? [If the answer to...

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a valid complete DHS form 8015 or eighty 16 for a ketchup exam must be on file in order for us to process the epsdt claim missing or invalid forms will result in payment delays or denial to ensure this requirement is met you should do one of the following attach the form to your claim if you are submitting a paper claim if you are submitting an electronic claim mail the completed form prior to sending the electronic claim transmission or if you are completing an electronic form 80 50 or 80 16 transmit the electronic forms before submitting your claims when filling out the paper forms use only the official version of the forms which revision date of January 2010 noted on the bottom left of the form using obsolete forms will result in payment delays photocopies of the form whether black and white or color are not acceptable as only the official forms enable optical scanning for data collection the service date on the claim must match the screening date on the DHS for maybe 15 and 80 16 u

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