Address SECTION II - Preauthorization General Information Pay to Provider Number Name Request Date Address Contact Telephone ( ) Provider’s Signature SECTION III Additional Preauthorization Information – Prescribing Provider ( ) Name Telephone Address SECTION IV Preauthorization Line Item Information – DESCRPTION PROCEDURE REQUESTED DATES OF SERVICE AUTHOR. OF SERVICE CODE MOD UNITS AMOUNT FROM THRU UNITS AMOUNT $ / / / / / / $ $ / / / / / / $ $ / / / / / / $ $ / / / / / / $ / / / / / / $ $ PREAUTHORIZATION NUMBER DOCUMENT CONTROL NUMBER SUBMIT TO: Program Systems and Operations Administration (STAMP HERE) Division of Claims Processing P.O. Box 17058 Baltimore, Maryland 21203 SECTION V Specific Preauthorization Information – Patient Location: Home Nursing Home Hospital In-Patient Discharge Date
Address SECTION II - Preauthorization General Information Pay to Provider Number Name Request Date Address Contact Provider’s Signature Telephone ( ) SECTION III – Additional Preauthorization Information Prescribing Provider Name Telephone ( ) Address SECTION IV – Preauthorization Line Item Information DESCRPTION OF SERVICE PROCEDURE REQUESTED DATES OF SERVICE AUTHOR. AMOUNT CODE MOD UNITS AMOUNT FROM THRU UNITS $ / / / / / / $ $ / / / / / / $ $ / / / / / / $ $ / / / / / / $ $ / / / / / / $ PREAUTHORIZATION NUMBER DOCUMENT CONTROL NUMBER SUBMIT TO: Program Systems and Operations Administration (STAMP HERE) Division of Claims Processing P.O. Box 17058 Baltimore, Maryland 21203 SECTION V – Specific Preauthorization Information Patient Location: Home Nursing Home Hospital In-Patient Discharge Date
EPSD-NEW-MANUAL-FINAL-01-12-17.docx