Get NV Prior Authorization and Referral Form 2004

NEVADA UNIVERSAL PRIOR AUTHORIZATION AND REFERRAL FORM HEALTH PLAN NAME MEMBER HEALTH PLAN I. D. Primary Care Provider Name / Address / Phone Fax Health Plan Phone 775-982-3700 Fax 775-982-3744 Date of Request Requesting Provider Name Patient s Name SS Insured Name SS Patient s Address Phone Patient s DOB HIPAA Provider Identification Contact Person Name Phone Fax Employer Group s Name Phone Other Insurance s Diagnosis inc. ICD code Procedure / Treatment Request inc. CPT code Number of Treatments Requested Inpatient / Outpatient Service Requested by Patient Yes No Service Provider / Address / Phone Place of Service / Facility and Address Requested Procedure Date / Start Treatment Date Current Clinical Findings and Management All procedures/treatment requested require clinical information may use this space - also see requirements below and attach to this form Pertinent Attachments Any information to support the proposed diagnosis treatment / procedure such as current clinical findings progress reports results of laboratory testing imaging studies x-rays etc. must be submitted to prevent processing delays. Area for internal health plan use only Health plan contact name phone Authorization Yes Date of Authorization No Pended / Denied Reason All sections of this form must be completed* On adverse determinations a reconsideration / expedited appeal may be requested* This referral/authorization is not a guarantee of payment. Payment is contingent upon eligibility benefits available at the time the service is rendered contractual terms limitations exclusions and coordination of benefits and other terms and conditions set forth in the Member s Evidence of Coverage Certificate of Coverage or Self Insured Employer s Plan Documents. The information contained in this form including attachments is privileged and confidential and is only for the use of the individual or entities named on this form* If the reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the intended recipient the reader is hereby notified that any dissemination distribution or copying of this communication is strictly prohibited* If this communication has been received in error the reader shall notify sender immediately and shall destroy all information received* Revised 8/2/04. Area for internal health plan use only Health plan contact name phone Authorization Yes Date of Authorization No Pended / Denied Reason All sections of this form must be completed* On adverse determinations a reconsideration / expedited appeal may be requested* This referral/authorization is not a guarantee of payment. Payment is contingent upon eligibility benefits available at the time the service is rendered contractual terms limitations exclusions and coordination of benefits and other terms and conditions set forth in the Member s Evidence of Coverage Certificate of Coverage or Self Insured Employer s Plan Documents. Payment is contingent upon eligibility benefits available at the time the service is rendered contractual terms limitations exclusions and coordination of benefits and other terms and conditions set forth in the Member s Evidence of Coverage Certificate of Coverage or Self Insured Employer s Plan Documents. The information contained in this form including attachments is privileged and confidential and is only for the use of the individual or entities named on this form* If the reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the intended recipient the reader is hereby notified that any dissemination distribution or copying of this communication is strictly prohibited* If this communication has been received in error the reader shall notify sender immediately and shall destroy all information received* Revised 8/2/04. .