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Prior authorization forms BANNER HEALTH NETWORK REFERRAL/PRIOR AUTHORIZATION FORM ATTENTION PATIENTS THIS IS YOUR REFERRAL FORM. THE SPECIALIST MAY REFUSE TO SEE YOU WITHOUT IT. Incomplete forms will not be processed and will be returned to sending provider. BANNER HEALTH NETWORK REFERRAL/PRIOR AUTHORIZATION FORM ATTENTION PATIENTS THIS IS YOUR REFERRAL FORM. THE SPECIALIST MAY REFUSE TO SEE YOU WITHOUT IT. Incomplete forms will not be processed and will be returned to sending provider. Planned Date of Service Recommend not scheduling until authorization is obtained Patient DOB Patient s Health Plan ID Requested Provider TIN Full Name Specialty Out of Network Inpt OutptOffice Office Contact Name Phone Fax Place of Service TIN Facility Name Referring Provider Phone Fax Requested Action by Specialist Optional for PCP to Complete Consultation Please send the patient back for follow-up and treatment Confirm Diagnosis Advise as to Diagnosis Suggest Medication or Treatment Referral Please provide PCP with summaries of subsequent visits Assume management for this particular problem and return patient after conclusion of care. Assume future management of patient within your area of expertise. Diagnosis/ICD-9 Treatment/Procedure with CPT/HCPCS codes Submit Information for request List units being administered Notes labs x-rays Provider Signature Date THE FOLLOWING APPLIES ONLY TO Banner Choice Plus PATIENTS To access your Banner Option Benefit your Primary Care Physician should refer you to a contracted provider. To ensure recommended provider is contracted call Banner Benefits Service Center at 480-684-7070 within Metro Phoenix area or at 800-827-2464 or go on the web www. BannerHealthPlans. com For Banner Use Only BHN Prior Authorization Dept Phone 480-684-7070 Fax 480-684-7200 within Metro Phoenix Area or 800-697-1441 The information contained in this facsimile message is confidential and intended only for the use of the individual s named above. If the reader of this message is not the intended recipient or the employee or agent 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 and destroy facsimile. THE SPECIALIST MAY REFUSE TO SEE YOU WITHOUT IT. Incomplete forms will not be processed and will be returned to sending provider. Planned Date of Service Recommend not scheduling until authorization is obtained Patient DOB Patient s Health Plan ID Requested Provider TIN Full Name Specialty Out of Network Inpt OutptOffice Office Contact Name Phone Fax Place of Service TIN Facility Name Referring Provider Phone Fax Requested Action by Specialist Optional for PCP to Complete Consultation Please send the patient back for follow-up and treatment Confirm Diagnosis Advise as to Diagnosis Suggest Medication or Treatment Referral Please provide PCP with summaries of subsequent visits Assume management for this particular problem and return patient after conclusion of care.

Dataformfillcom OVERSEAS PRE-EMPLOYMENT DATA FORM Personal Data: Name: Social Security Number: Citizenship: Date of Birth: Typing-Words Per Minute: Employee Preferences Work Schedule: Full Time: Part Time: Minimum

Authorization for release of p... Form 526A Page 1 of 2 PLEASE FAX OR EMAIL THIS COMPLETED FORM TO: The Little Clinic LLC Attn: Medical Records Department Fax: (615) 425-4344 OR medicalrecords thelittleclinic.com AUTHORIZATION FOR

Dealership form Dealer Payoff Worksheet 4Owner Information OWNER NAME STREET ADDRESS CITY STATE ZIP 4Vehicle Information Y EAR TITLE STATE / TITLE # MAKE MODEL VIN TITLE TYPE Paper 4Lienholder Information LIENHOLDER

Nh magellan medicaid prior aut... Hyaluronic Acid Derivatives Injection New Hampshire Medicaid Prior Authorization Request Form Fax to Magellan if medication is to be dispensed from a pharmacy Magellan Fax 1-888-603-7696 Phone 1-866-675-7755 Fax to KePRO if medication is dispensed/administered by a physician in the office or outpatient setting KePRO Fax 1-800-922-9847 Phone 1-800-299-5921 DATE OF MEDICATION REQUES T Section I Patient Information and Medication Request NAME LAS T ...

Credit card authorization temp... Credit Card Authorization Department of State Division of Licensing Services P.O. Box 22001 Albany, NY 12201-2001 The Department of State's Division of Licensing Services accepts MasterCard and Visa

Authorized signatory template... Sample Authorization Letter to Open an FRG Checking Account Unit Letterhead Office Symbol (600-20) Bank Name ATTENTION: New Business Accounts Bank Address City, State ZIP SUBJECT: Authorization to

Flood acknowledgement form DEPARTMENT OF HOMELAND SECURITY - FEDERAL EMERGENCY MANAGEMENT AGENCY O.M.B. NO. 1660-0015 Expires February 28, 2014 COMMUNITY ACKNOWLEDGMENT FORM PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting

Cleveland clinic florida autho... AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION Patient Name: Last First Middle Home Address: Home Telephone: Date of Birth: Social Security Number: Specify Information to be Disclosed/Brief

Los colinas medical center aut... ' #$% &$' ( )*++ , $- #$% ./& ' ! & #& &50'* 0 1& 2 3- 1 #3+ # & +$ - 4+$ 50 & 0464 ' 7 8 *0& + 6 '0& ' & & )0& 9+ 6* 8 ' &$

Authorization form mim 710 s u... AUTHORIZATION FORM ? MIM #710-S For Radiology Films please send: 500 Eastowne Drive Chapel Hill, NC 27514 For all other record requests please send: ATTN: IMAGING SUPPORT ATTN: RELEASE OF MEDICAL

Concentra patient form Patient Information Patient Last name: First name: Social Security #: Date of birth (MM/DD/YYYY): Driver s License number: Issued in what state: License classification: Address: City: ST: Contact

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