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Get And Sign Pre Authorization Form 2018-2021

Complete. Please send completed form to GBG Assist: • Email: gbgassist@gbg.com • Fax: +1.949.271.5038 A. PATIENT INFORMATION Name (Last, First, MI): Policy #: GBG ID #: Date of Birth: (DD/MMM/YYYY, i.e., 23/NOV/1988) Employer (if applicable): Address: Postal Code: Country: Phone: Fax: Email: B. PRE-AUTHORIZATION REQUEST Procedure/treatment name: Is the patient having surgery? ☐ Yes ☐ No If Yes, what type of anesthesia is required? ☐ Local ☐ General ☐ Or Sedation Expected...

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