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Get and Sign Pre Authorization Form 2018-2022
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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