Prior Authorization Services
IF THIS IS AN URGENT REQUEST PLEASE COMPLETE AND SUBMIT THE FORM BELOW, AND CALL THE PRIOR AUTHORIZATION TEAM DIRECTLY TO SCHEDULE THE APPOINTMENT (870)541-7610
REFERRING CLINIC INFORMATION
Referring Clinic Name
Ordering Provider Name
Ordering Provider NPI
Referring Provider Office Contact Person
Please enter name and phone number of person that can be contacted for any questions
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Provider Phone Number
Format: (000) 000-0000.
Referring Provider Fax Number
Format: (000) 000-0000.
PATIENT INFORMATION
Patient Name
First
Last
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Testing Information
Test Ordered
*
CPT Code
*
Comments
Comments
Please upload or fax the following information when submitting this request: Copy of the order Patient demographic information (Name, DOB, SSN, Address, Phone) Insurance card and copy (front & Back, for all insurances held by patient Worker's Compensation/auto insurance information (if applicable) Most recent office notes or prior studies pertaining to the study
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