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Get Pre Authorization Form Download 2018-2024

G pre-authorization. Otherwise, penalty co-pay will be applied to your claims, and the provider may decline to direct bill us. Your policy has requirements regarding the pre-authorization of certain treatments/procedures. Non-emergency authorizations may take up to 5 business days to complete. Please send completed form to GBG Assist: Email: gbgassist gbg.com Fax: +1.949.271.5038 A. PATIENT INFORMATION Name (Last, First, MI): Policy #: GBG ID #: Date of Birth: (DD/MMM/YYYY, i.e., 23/N.

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