Orthopedic Procedure Pre-Authorization Request Form
Patient Information
Full Name
Date of Birth
Gender
Male
Female
Other
Patient ID / MRN
Phone
Insurance Provider
Policy Number
Provider Information
Referring Physician
Physician NPI
Practice/Facility Name
Contact Number
Procedure Details
Procedure Requested
CPT/HCPCS Code
Diagnosis / ICD Code
Procedure Date
Facility Name
Clinical Information
Reason for Procedure
Conservative Treatments Tried
Supporting Documents / Notes
Additional Information
Comments