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Prior Authorization Request Form Form Must Be Filled Out Completely And Legibly Submission of request form required for NYS of Health Managed Medicaid CHP FHP and Medicare Advantage Fax 800 860-8720 Fidelis Care Member Name Last First M. I. Questions 888 343-3547 Patient / Member Information Services CPT/Procedure Code s and Description ICD- 10 Diagnosis Dx Code s Date of Birth mm/dd/yyyy Check if applicable Medicare No-Fault Workers Comp Date of Injury mm/dd/yyyy Date of Procedure if applicable mm/dd/yyyy Provider Name Phone Tax ID or NPI Include area codes Fax IPA Affiliation if applicable Inpatient Facility Name and Tax ID or NPI Outpatient/Ambulatory/23 Hour This Request is Urgent/Emergent Additional Information Pre-service Please Submit the following clinical information with this form as appropriate for this request circle all included History Physical Current Symptoms and Functional Impairment Treatment history Lab/Radiology testing results Pictures Medical record chart notes This form is to be filled out in its entirety for Initial and Concurrent requests please fax to 1-800-860-8720. Prior Authorization Request Form Form Must Be Filled Out Completely And Legibly Submission of request form required for NYS of Health Managed Medicaid CHP FHP and Medicare Advantage Fax 800 860-8720 Fidelis Care Member Name Last First M. I. Questions 888 343-3547 Patient / Member Information Services CPT/Procedure Code s and Description ICD- 10 Diagnosis Dx Code s Date of Birth mm/dd/yyyy Check if applicable Medicare No-Fault Workers Comp Date of Injury mm/dd/yyyy Date of Procedure if applicable mm/dd/yyyy Provider Name Phone Tax ID or NPI Include area codes Fax IPA Affiliation if applicable Inpatient Facility Name and Tax ID or NPI Outpatient/Ambulatory/23 Hour This Request is Urgent/Emergent Additional Information Pre-service Please Submit the following clinical information with this form as appropriate for this request circle all included History Physical Current Symptoms and Functional Impairment Treatment history Lab/Radiology testing results Pictures Medical record chart notes This form is to be filled out in its entirety for Initial and Concurrent requests please fax to 1-800-860-8720. You will be notified of the service determination within the appropriate regulatory timeframe All requests for services require additional clinical to support the requested service s including but not limited to History Physical previous diagnostic tests and consultation reports Prescription from prescribing physician* Confirmation and/or authorization do not guarantee that benefits will be paid* Payment of claims is subject to member eligibility. I. Questions 888 343-3547 Patient / Member Information Services CPT/Procedure Code s and Description ICD- 10 Diagnosis Dx Code s Date of Birth mm/dd/yyyy Check if applicable Medicare No-Fault Workers Comp Date of Injury mm/dd/yyyy Date of Procedure if applicable mm/dd/yyyy Provider Name Phone Tax ID or NPI Include area codes Fax IPA Affiliation if applicable Inpatient Facility Name and Tax ID or NPI Outpatient/Ambulatory/23 Hour This Request is Urgent/Emergent Additional Information Pre-service Please Submit the following clinical information with this form as appropriate for this request circle all included History Physical Current Symptoms and Functional Impairment Treatment history Lab/Radiology testing results Pictures Medical record chart notes This form is to be filled out in its entirety for Initial and Concurrent requests please fax to 1-800-860-8720. You will be notified of the service determination within the appropriate regulatory timeframe All requests for services require additional clinical to support the requested service s including but not limited to History Physical previous diagnostic tests and consultation reports Prescription from prescribing physician* Confirmation and/or authorization do not guarantee that benefits will be paid* Payment of claims is subject to member eligibility.