Radiology Imaging Pre-Authorization Request Form
Patient Information
Full Name
Date of Birth
Member ID
Phone Number
Address
Provider Information
Referring Provider Name
Provider NPI
Phone
Fax
Insurance Information
Insurance Name
Group Number
Plan Name
Authorization Number
Imaging Request Details
Type of Imaging
CT
MRI
Ultrasound
X-ray
PET
Other
Body Part
ICD-10 Diagnosis Code(s)
CPT Code(s) Requested
Clinical Indication/Reason for Study
Additional Information
Previous Relevant Imaging (Date/Type/Facility)
Notes / Comments