Get Back Injection Preauthorization Form - Innovative Care Management

Filling out the Back Injection Preauthorization Form is an essential step in receiving the necessary preauthorization for various injection procedures. This guide will provide clear and detailed instructions on how to complete the form efficiently and accurately online.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the Back Injection Preauthorization Form and open it in your chosen document editor.
2. Begin by entering the patient’s name and date of birth in the appropriate fields at the top of the form.
3. Fill in the details of the submitter, including their name, phone number, and fax number.
4. Provide the physician's information by entering their name, phone number, and fax number in the designated areas.
5. Specify the facility's name and contact number where the procedure will be performed.
6. Indicate the type of injection requested by selecting one of the options provided, such as epidural steroid injection or facet injection.
7. Enter the CPT and ICD9 codes related to the injection procedure in the specified fields.
8. Identify the level(s) of injection required, such as L5-S1, in the designated areas of the form.
9. If applicable, indicate if the injection is bilateral or unilateral, and specify the side if it is unilateral.
10. Provide the date of service for the injection request or check the box labeled 'Not Scheduled' if the date has not been determined.
11. Answer the questions regarding the patient’s medical history by checking the appropriate boxes for any conditions they may have.
12. Indicate whether the patient has been treated with anti-inflammatory drugs and for how long, if applicable.
13. Fill out the treatment history for conservative therapies, specifying any treatments like physical therapy or chiropractic care.
14. Indicate if the patient has had a prior spinal injection at the same level, along with details if applicable.
15. If the patient has received injections in the last 12 months, provide the dates, types, levels, responses, and duration of pain relief.
16. Review all entries for accuracy, then save the completed form, and if necessary, download, print, or share it as needed.

Take the next step towards your treatment by completing the Back Injection Preauthorization Form online today.