Get Tar Form Medical

D. Board Care DATE MM/DD/YY REVIEW COMMENT INDICATOR COMMENTS/EXPLANATION SMMC MR Diagnosis Description Medical Justification Line No. Authorized Yes No Approved Units Service Specific Services Requested NDC/UPC or Procedure Code Quantity Charges To the best of my knowledge the above information is true accurate and complete and the requested services are medically indicated and necessary to the health of the patient. Authorization is Valid for Services Provided From Date MM/DD/YY TAR Control Number Signature of Physician or Provider Title Date Office Sequence Number PI NOTE AUTHORIZATION DOES NOT GUARANTEE PAYMENT. CA 701 Gateway Blvd. Suite 400 South San Francisco CA 94080 TEL 650-616-0050 TTY 1-800-735-2929 For authorization questions contact HPSM Health Services Ph 650. 616. 2070 Fax 650. 829. 2079 Treatment Authorization Request 50-1 PLEASE TYPE FOR PROVIDER USE Verbal Control No* Type of Service Requested Drug Request is Retroactive Other Yes No Patient s Authorized Representative If Any Enter Name and Address Provider Phone No* Provider Fax No* PROVIDER NAME AND ADDRESS NPI Number s FOR HPSM USE Provider Your Request is APPROVED AS REQUESTED DENIED DEFERRED APPROVED AS MODIFIED ITEMS MARKED BELOW AS Name and Address of Patient Last First M. I. Member Identification Number AUTHORIZED MAY BE CLAIMED Sex Street address Age Date of Birth REVIEWER City State Zip Code SNF/ICF Home Phone Number ICD9 Code SMMC Account Number SMMC Type of Service / Patient Status Acute Hospital I. D. Board Care DATE MM/DD/YY REVIEW COMMENT INDICATOR COMMENTS/EXPLANATION SMMC MR Diagnosis Description Medical Justification Line No* Authorized Yes No Approved Units Service Specific Services Requested NDC/UPC or Procedure Code Quantity Charges To the best of my knowledge the above information is true accurate and complete and the requested services are medically indicated and necessary to the health of the patient. Authorization is Valid for Services Provided From Date MM/DD/YY TAR Control Number Signature of Physician or Provider Title Date Office Sequence Number PI NOTE AUTHORIZATION DOES NOT GUARANTEE PAYMENT. PAYMENT IS SUBJECT TO PATIENT S ELIGIBILITY. BE SURE THE ID CARD IS CURRENT BEFORE RENDERING SERVICE* TAR 50-1 CAJanuary 2013. CA 701 Gateway Blvd. Suite 400 South San Francisco CA 94080 TEL 650-616-0050 TTY 1-800-735-2929 For authorization questions contact HPSM Health Services Ph 650. 616. 2070 Fax 650. 829. 2079 Treatment Authorization Request 50-1 PLEASE TYPE FOR PROVIDER USE Verbal Control No* Type of Service Requested Drug Request is Retroactive Other Yes No Patient s Authorized Representative If Any Enter Name and Address Provider Phone No* Provider Fax No* PROVIDER NAME AND ADDRESS NPI Number s FOR HPSM USE Provider Your Request is APPROVED AS REQUESTED DENIED DEFERRED APPROVED AS MODIFIED ITEMS MARKED BELOW AS Name and Address of Patient Last First M. 616. 2070 Fax 650. 829. 2079 Treatment Authorization Request 50-1 PLEASE TYPE FOR PROVIDER USE Verbal Control No* Type of Service Requested Drug Request is Retroactive Other Yes No Patient s Authorized Representative If Any Enter Name and Address Provider Phone No* Provider Fax No* PROVIDER NAME AND ADDRESS NPI Number s FOR HPSM USE Provider Your Request is APPROVED AS REQUESTED DENIED DEFERRED APPROVED AS MODIFIED ITEMS MARKED BELOW AS Name and Address of Patient Last First M. I. Member Identification Number AUTHORIZED MAY BE CLAIMED Sex Street address Age Date of Birth REVIEWER City State Zip Code SNF/ICF Home Phone Number ICD9 Code SMMC Account Number SMMC Type of Service / Patient Status Acute Hospital I.