Prosthetic Device Pre-Authorization Request Form
Patient Information
Full Name
Date of Birth
Patient ID / MRN
Phone Number
Insurance Provider
Policy Number
Prescribing Physician Information
Physician Name
NPI Number
Phone Number
Email
Facility Name
Fax Number
Prosthetic Device Details
Type of Device
HCPCS / CPT Code
Laterality
Left
Right
Bilateral
Medical Necessity / Clinical Rationale
Requested Date of Service
Supporting Documentation
List attached documents
Comments / Additional Information