Pre-Authorization Request Fax Request to: 800-580-3123 ...

Pre-Authorization Request Fax Request to: 800-580-3123

Email: UR@

P.O. Box 81665 Austin, Texas 78708 Phone: (800) 580-2273 Fax: (800) 580-3123

Claimant Name: Address: City: State, Zip

Claimant Information Social Security #: DOB: Phone:

Employer Name: Address: City: State, Zip

Employer Information Phone: FEIN:

Insurance Carrier: Address: City: State, Zip

Workers' Compensation Insurance Information Claim Number: DOI: Phone: Adjuster Name:

Doctor Name: Address: City: State, Zip

Requesting Provider Phone: Fax: Tax ID: NPI or License #:

Facility Name: Address: City: State, Zip

Facility Where Services Will Be Provided (if applicable) Phone: Fax: Tax ID: NPI or License #:

Procedure/Service: DX Code(s): CPT Code(s): Date of Service(s)

Requested Procedure/Services

(Date services expected to be rendered)

Name: Mailing Address: Phone: Fax:

Defense Attorney Information

Name: Mailing Address: Phone: Fax:

Applicant Attorney Information

Are clinicals attached to support requested services? Is this an Appeal? Notes/Comments:

_____ Yes ____ No _____ Yes ____ No

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