CONNECT Portal
ALTAMED PACE SENIOR BUENACARE-AUTHORIZATION REQUEST FORM
URGENT (72 HOURS) Requests submitted as an urgent referral when standard timeframes could seriously jeopardize the Member's life or health or ability to attain, maintain or regain maximum function.
ROUTINE (5 BUSINESS DAYS/*14 CALENDAR DAYS)
RETRO (30 CALENDAR DAYS) Request must be submitted within 30 calendar days from service date
For Inquiries or questions on authorization status or for general questions call the AltaMed PACE UM Department at:
(323) 597-2972.
Continuity of Care Standing Referral Second Opinion
SUBMIT AUTHORIZATION REQUEST VIA FAX TO (323) 201-3226
REQUEST DATE: _________________
PATIENT INFORMATION
| | |
|Patient’s Name: |DOB: |
| | |
| |Health Plan ID: |
|Health Plan: | |
AUTHORIZATION REQUEST INFORMATION
DIAGNOSIS: ______________________________________ ICD-10: __________________________________________
REFERRED TO PROVIDER: ________________________________________________________________________________
ADDRESS/Telephone: _______________________________________________________________________________________
NPI/TAX ID: _______________________________________________________________________________________________
REASON FOR REFERRAL:
___________________________________________________________________________________________________________
CPT Code: ______________________ CPT Description: ____________________________________________________
______________________ ____________________________________________________ ______________________ ____________________________________________________
TREATMENT AND WORK-UP DONE WITH RESULTS:
____________________________________________________________________________________________________________________________________________________________________________________________________
ATTACHMENTS:
Clinicals Laboratory & Radiology Findings Medication List Other
___________________________________________ _____________________________________________
(Requesting Provider Signature) (Print Physician’s Name)
Requesting Provider Address: __________________________________________________________________________________________________
Requesting Provider Phone: ___________________ Requesting Provider Fax: ______________________________
Office Contact Name/Telephone: ______________________________
Primary Care Physician (If different than referring Provider):_______________________________________________
INTERNAL USE ONLY: ___________________________________________________________________________
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