Outpatient Surgery Pre-Authorization Request Form
Patient Information
Patient Name
Date of Birth
Member ID
Phone
Address
Provider Information
Provider Name
NPI Number
Contact Phone
Contact Email
Facility Name
Surgery Information
Surgery Type/Procedure
Proposed Date
CPT/Procedure Code(s)
ICD Diagnosis Code(s)
Medical Necessity/Reason for Surgery
Supporting Information
Relevant Past Treatments and Outcomes
Additional Comments