Non Surgical Interventional Pain Management Step 1 of 4 25% Member Information Enter 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 Provider InformationPlace of service NPI* 10 digitsPlace of service for injection* Error Message Ordering MD* Phone #*Fax #*Contact Name* Email address in order to receive confirmation of request receipt* Clinical InformationCPT Code(s) and units for each (Click + or - at the right to add up to 5 CPT Codes)*CPT CodeUnits Example CPT code: 12345Levels*Anatomic Location to be treated* Bilateral Unilateral Right Left Anesthesia* Local MAC Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890Procedure Requested* Epidural Steroid Injection Spinal Facet Joint Injection Sacroiliac Injection Radio Frequency Nerve Ablation Other Please attach clinical notes that include ALL of the following Last injection/injection history Previous physical therapy Comprehensive pain management treatment plan Relief from last injection Pain medication used Provocative testing results Functional impairment 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*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.Attach only PDF and Word filesSignature of Physician or Licensed Provider*Signature Date* CommentsAuthorization is not a guarantee of paymentCAPTCHA