Chiropractic Care Pre-Authorization Request Form
Patient Information
Name
Date of Birth
Member ID
Address
Phone
Provider Information
Provider Name
NPI Number
Phone
Fax
Clinical Information
Diagnosis (ICD-10)
Date of Onset/Exacerbation
Accident Type
Work Related
Auto
Other
Not Applicable
Clinical Summary
Treatment Plan
Requested Services
CPT Codes
# of Visits Requested
Frequency
Additional Information
Notes
Provider Signature
Date