Prior Authorization form

Provider Information

OFFICE CONTACT

Patient Information

Please enter all codes requested; “by report” codes must have a description of why the code is being used

Please Provide the following documentation:

History and physical and/or consultation notes including:

• Clinical findings (e.g., pertinent symptoms an duration
• Comorbidities
• Activity and functional limitations
• Family history if applicable
• Reason for procedure/test/device, when applicable
• Pertinent past procedural ad surgical history
• Past and present diagnostic testing and results
• Prior conservative treatments, duration and response
• Treatment plan (e.g., surgical intervention)

Consultation and medical clearance report(s), when applicable

Radiology report(s) and interpretation (e.g., MRI, CT, discogram)

Laboratory results

Other pertinent multidisciplinary notes/reports: when applicable (e.g., psychological or psychiatric evaluation, physical therapy, multidisciplinary pain management)

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