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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