AUTHORIZATION REQUEST FORM Please fax completed form to appropriate L.A. Care UM Department fax number listed below: Prior Authorization: (213) 438-5777 Urgent: (213) 438-6100 Inpatient: (877) 314-4957 Delegate Support Team (DST): (213) 438-5761 Transplant: (213) 438-5071 Medicare: (213) 438-5077 CAN Network: (213) 438-5680 If the treating physician would like to discuss this case with the physician or health care professional reviewer or obtain a copy of the criteria used to make this decision, please call 1-877-431-2273. REQUEST INFORMATION Request Date: Request Status: ❑Urgent ❑Routine Request Type: (check one) ❑Prior ❑Concurrent ❑Post Service PATIENT INFORMATION Member Name: Date of Birth: Preferred Written Language: Member ID: Address: City: Zip: Phone: PCP: PPG: Line of Business (check one): ❑MCLA ❑Cal MediConnect ❑L.A. Care Covered ❑PASC-SEIU REQUEST – SERVICE TYPE REQUESTED ❑Acute Hospital, Community ❑DME Expected Duration: _________ ❑Nursing Facility, short term skilled care ❑Acute Hospital, Tertiary ❑Hemodialysis ❑Palliative Care ❑Ambulatory Surgery Center ❑Home Health ❑Prosthetic/Orthotics ❑CBAS - Initial request ❑Hospice ❑Transgender Health ❑CBAS - Renewal ❑Long Term Care – Initial Request ❑Transplant Evaluation ❑Diagnostic Procedure/Radiology ❑Long Term Care – Renewal ❑Other (Specify): ___________________ PROVIDER SUBMITTING REQUEST Requesting Provider Name: Specialty: Phone Number: Fax Number: NPI: Address: City: Zip: PROVIDER PERFORMING/PROVIDING SERVICE Requested Provider Name: Specialty: Phone Number: Fax Number: NPI: Address: City: Zip: DIAGNOSIS/PROCEDURE INFORMATION Clinical Indications for request (include pertinent past medical treatment, physical findings and attach all relevant medical records, test results, etc.): ICD-10 Code(s)/Description: CPT Code(s)/Description: HCPCS Code(s)/Description (If available): Is the service being requested out of network? ❑No ❑Yes If yes, please provide reason for using an out of network facility: Provider Name: (Print) Provider Signature: Date: Rev. 12.14.17 AUTHORIZATION IS CONTINGENT UPON MEMBER’S ELIGIBILITY ON DATE OF SERVICE Do not schedule non-emergent requested service until authorization is obtained.

Authorization Request Form - L.A. Care Health Plan · AUTHORIZATION REQUEST FORM ... AUTHORIZATION IS CONTINGENT UPON MEMBER’S ELIGIBILITY ON DATE OF SERVICE Donotschedule non …

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AUTHORIZATION REQUESTFORM

Please fax completed form to appropriate L.A. Care UM Department fax number listed below:

Prior Authorization: (213) 438-5777 Urgent: (213) 438-6100 Inpatient: (877)314-4957 DelegateSupport Team (DST):(213) 438-5761

Transplant: (213) 438-5071 Medicare: (213) 438-5077 CAN Network: (213) 438-5680

If the treating physician would like to discuss this case with the physician or health care professionalreviewer or obtaina copy of the criteria used to makethisdecision, pleasecall 1-877-431-2273.

REQUEST INFORMATION Request Date: Request Status: ❑Urgent ❑Routine Request Type: (check one) ❑Prior ❑Concurrent ❑Post Service PATIENT INFORMATION Member Name: Date of Birth: Preferred Written Language: Member ID: Address: City: Zip: Phone: PCP: PPG: Lineof Business (checkone): ❑MCLA ❑Cal MediConnect ❑L.A. CareCovered ❑PASC-SEIU REQUEST – SERVICETYPEREQUESTED ❑Acute Hospital, Community ❑DME Expected Duration: _________ ❑Nursing Facility, short term skilled care ❑Acute Hospital, Tertiary ❑Hemodialysis ❑PalliativeCare❑Ambulatory Surgery Center ❑Home Health ❑Prosthetic/Orthotics ❑CBAS - Initialrequest ❑Hospice ❑Transgender Health ❑CBAS - Renewal ❑LongTerm Care – InitialRequest ❑Transplant Evaluation ❑Diagnostic Procedure/Radiology ❑LongTerm Care– Renewal ❑Other (Specify): ___________________ PROVIDERSUBMITTING REQUEST Requesting Provider Name: Specialty: PhoneNumber: Fax Number: NPI: Address: City: Zip: PROVIDERPERFORMING/PROVIDING SERVICE RequestedProvider Name: Specialty: PhoneNumber: Fax Number: NPI: Address: City: Zip: DIAGNOSIS/PROCEDURE INFORMATION Clinical Indications for request (include pertinent past medical treatment, physical findings andattachall relevant medical records, testresults, etc.):

ICD-10Code(s)/Description:

CPT Code(s)/Description:

HCPCS Code(s)/Description (If available):

Is the service being requested out of network? ❑No ❑Yes If yes,please provide reason for using an out of network facility:

Provider Name: (Print) Provider Signature: Date:

Rev. 12.14.17 AUTHORIZATIONIS CONTINGENT UPONMEMBER’S ELIGIBILITY ONDATE OF SERVICE Do not schedule non-emergent requestedserviceuntil authorizationis obtained.