General Authorization Form Step 1 of 3 33% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form.Member's ID#* Member's DOB* MM slash DD slash YYYY Date of Service (if known) MM slash DD slash YYYY Name* First Last Error Message Facility InformationHospital/Facility NPI* 10 digitsHospital/Facility Name* where procedure will take placeError Message Type of request* Outpatient Inpatient Ordering MD* Contact Name* Contact Phone #*Contact Fax #*Email address in order to receive confirmation of request receipt* Clinical InformationCPT Code(s) (Click + or - at the right to add more CPT Codes)*CPT CodeUnits Example CPT code: 12345Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Description of procedure*Attach Clinical* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Upload only PDF or Word DocumentSignature of Treating Physician*Reset to re-sign.Signature Date:* Request Method* Standard Expedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited. Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 13 MB.Upload only PDF or Word DocumentsSignature of Physician or Licensed Provider (Required for Expedited request)*Reset to re-sign.Signature Date:* CommentsAuthorization is not a guarantee of paymentCAPTCHA