Prior Authorization Request Form
Required for: Metal-Level Products, Managed Medicaid, CHP, and Medicare Advantage
Fax: (800) 860-8720 Questions: (888) 343-3547
Member Information
Fidelis Care Member Name (Last, First, M.I.):
Fidelis Care Member ID #:
Date of Birth:
/ /
Services
ICD-10 Diagnosis (Dx) Code(s):
CPT/Procedure Code(s) and Description:
Check if applicable:
[ ] Medicare [ ] Workers' Comp
[ ] No-Fault
Date of Injury: / /
Date of Procedure
(if applicable):
/ /
Servicing Provider Name:
Servicing Provider Phone #: ( ) -
Servicing Provider Tax ID #:
Servicing Provider Address:
Servicing Provider Fax #: ( ) -
Servicing Provider NPI #:
Provider IPA Affiliation (if applicable):
Requesting Provider Name:
Requesting Provider Tax ID / NPI:
Check if applicable:
[ ] Inpatient
[ ] Outpatient/Ambulatory/23 Hour
Facility Name:
Facility Tax ID#:
This Request is:
[ ] Urgent/Emergent
[ ] Pre-service
[ ] Post-service
[ ] Concurrent service
Auth #:____________________
Additional Information:
Please submit the following clinical information with this form as appropriate for this request (check all included):
[ ] History & Physical [ ] Current Symptoms and Functional Impairment
[ ] Treatment history [ ] Lab/Radiology testing results
[ ] Pictures [ ] Medical record (chart notes)
This form is to be filled out in its entirety for Initial and Concurrent requests; please fax to 1-800-860-8720.
You will be notified of the service determination within the appropriate regulatory timeframe.
All requests for services require additional clinical to support the requested service(s) including but not limited
to: History & Physical, previous diagnostic tests, and consultation reports, Prescription from prescribing
physician.
Confirmation and/or authorization do not guarantee that benefits will be paid. Payment of claims is subject to
member eligibility.
Rev. 5.22.2019
Facility NPI #:
