Inpatient Hospital Admission Pre-Authorization Request Form
Patient Information
Full Name
Date of Birth
Member/Policy Number
Phone Number
Address
Provider Information
Referring Provider Name
NPI Number
Provider Phone
Facility Name
Facility Address
Admission Details
Admission Date
Type of Admission
Elective
Emergency
Urgent
Expected Length of Stay (Days)
Clinical Information
Primary Diagnosis
Reason for Admission / Clinical Justification
Treatment Plan
Insurance Information
Primary Insurance
Group Number
Authorization Number
Additional Information
Comments