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Get And Sign XO PAF 1650 Outpatient Oregon Healthnet Medicare Authorization Form Outpatient Oregon Healthnet Medicare Authorization Form

Last Name First REQUESTING PROVIDER INFORMATION Requesting NPI Requesting Provider Contact Name Fax Phone SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Provider Servicing NPI Servicing Provider/Facility Name AUTHORIZATION REQUEST Additional Procedure Code Modifier CPT/HCPCS If this request is for a Part B DRUG please fax to 844-978-0975 Primary Procedure Code OUTPATIENT SERVICE TYPE Start Date OR Admission Date Diagnosis Code ICD-10 End Date OR Discharge Date Total...

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