DENTAL PRIOR AUTHORIZATION REQUEST FORM

Requesting provider NPI (or IHCP Provider ID)

Requesting provider

Mail-to provider (If different)

Requesting Provider Tax ID

Requesting Provider Tax ID :Requesting provider

Requesting Provider Tax ID :Mail-to provider

Dentist Name

Name :Requesting provider(Required)

Name :Mail-to provider

Telephone

Telephone :Requesting provider

Telephone :Mail-to provider

Taxonomy

Taxonomy :Requesting provider

Taxonomy :Mail-to provider

Service location ZIP Code + 4

Service location ZIP Code + 4 :Requesting provider

Service location ZIP Code + 4 :Mail-to provider

Member name

Member address

Member ID/ Policy

Member date of birth

Dates of service		Requested service		Place of service	Units	Dollars
Start MMDDYYYY	Stop MMDDYYYY	Procedure code REQUIRED	Description	Place of service	Units	Dollars
Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY	Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY Date MM slash DD slash YYYY	Procedure code 1 Procedure code 2 Procedure code 3 Procedure code 4 Procedure code 5 Procedure code 6 Procedure code 7	Description 1 Description 2 Description 3 Description 4 Description 5 Description 6 Description 7	Place of service 1 Place of service 2 Place of service 3 Place of service 4 Place of service 5 Place of service 6 Place of service 7	Units 1 Units 2 Units 3 Units 4 Units 5 Units 6 Units 7	Dollars 1 Dollars 2 Dollars 3 Dollars 4 Dollars 5 Dollars 6 Dollars 7