☐ Other (please specify): ____________________________________
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Outpatient Authorization Request Form
*Indicates a required field
Requirements: Clinical information and supportive documentation should consist of current physician orders, notes
and recent diagnostics. Notification is required for any date-of-service change.
Expedited Requests: If the standard time for making a determination could seriously jeopardize the life and/or
health of the member or the member's ability to regain maximum function, please call 1-855-538-0454.
Please fax completed form to appropriate number at bottom of form.
Requestor
Name:
Fax*#: Phone*#:
______________________
______________________________
_____________________________
MEMBER INFO (Please Print)
Wellcare ID*:
Medicaid/Medicare ID:
Last Name*: First Name, MI*: Date of Birth*: / /
REQUESTING PROVIDER (Please Print)
Wellcare ID:
NPI/Tax ID*:
Provider Name*:
Address:
City, State, ZIP:
Fax*: Phone:
SERVICING PROVIDER OR FACILITY (Please Print)
Wellcare ID:
NPI/Tax ID*:
Provider/Facility Name*:
Address:
City, State, ZIP:
Fax*: Phone:
TREATING PROVIDER (Please Print)
Wellcare ID:
NPI/Tax ID*:
Provider/Facility Name*:
Address:
City, State, ZIP:
Fax*: Phone:
DIAGNOSIS CODES*
ICD-10:
ICD-10:
ICD-10: ICD-10:
REQUESTED SERVICES
☐
Dialysis
☐
Office Visit/Procedure
☐
Radiation Therapy
☐
MRI
☐
Sleep Study
☐
X-Rays
☐
CT Scan
☐
Other (please specify):
________________________________________________________________________
Place of Service (check one): ☐ Telehealth (02) ☐ Office (11) ☐ Outpatient Hospital (22)
☐ Dialysis Center (65) ☐ Lab (81)
Anticipated Service Da te*:
_____
/
_____
/
_____
PROCEDURE CODE(S)* Description PROCEDURE CODE(S) Description
CPT Code: CPT Code:
CPT Code: CPT Code:
CPT Code: CPT Code:
PRO_84650E Internal Approved 04082021
©Wellcare 2021
NA1PROFRM84650E_0000
Fax completed form to:
Medicare Fax Lines
Arizona Value (HMO)
855-754-8483
Arizona Patriot (PPO)
866-246-9832
Connecticut 866-455-6529
Florida Medicare Only
877-892-8216
Georgia Medicare Only
877-892-8213
Florida/Georgia Dual
877-277-1820
Illinois 877-899-2044 Kentucky 888-361-5684 New Jersey 877-892-8221
New York 877-892-8214 Texas 877-894-2034 All others 888-361-5684
PRO_84650E Internal Approved MMDDYYYY
©Wellcare 2021
NA1PROFRM84650E_0000