Prior Authorization

Patient Name: (*)

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Patient date of birth:

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Email address (where notification should be sent):

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Phone (where HealthShare may reach you with questions)

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Name of doctor ordering the test or special service or making the referral:

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If the prior authorization is for a referral, enter the name of the specialist doctor you are going to see:

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Diagnosis

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Reason for the test, special service or referral.

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Location of the test or special service

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Date of appointment

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Time of appointment:

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