TEMPLATE - Medicaid Prior Authorization for Elective CABG (Use this template to gather information from Surgeon and enter into Web system. Do not fax to eQHealth.) eQSuite™ Request Date: _______________________ Elective CABG MEDICAID PARTICIPANT INFORMATION Participant Name: Medicaid ID #: Last, First, Middle Sex: Age: ___________________________________________________ // Date of Birth: HOSPITAL/REQUESTOR INFORMATION INFORMATION PHYSICIAN’S Attending(Surgeon) Name: Hospital’s Last, First, Middle Name: Initial Physician’s ___________________________________________________ Medicaid 12-Digit Provider ID #: Street Address: ______________________________________ City: _______________________________________________ Requestor: State: ______________________________________________ - ___________________________________________________ Zip Code: () - Phone #:
TEMPLATE - Medicaid Prior Authorization for Elective CABG (Use this template to gather information from Surgeon and enter into eQSuite™ Web system. Do not fax to eQHealth.) Request Date: _______________________ Elective CABG MEDICAID PARTICIPANT INFORMATION Participant Name: Last, First, Middle ___________________________________________________ Date of Birth: // Medicaid ID #: Sex: Age: HOSPITAL/REQUESTOR INFORMATION PHYSICIAN’S INFORMATION Hospital’s Name: ___________________________________________________ Medicaid 12-Digit Provider ID #: Requestor: ___________________________________________________ Phone #: () - Attending(Surgeon) Physician’s Name: Last, First, Middle Initial Street Address: ______________________________________ City: _______________________________________________ State: ______________________________________________ Zip Code: -
Prior%20Auth%20Provider%20Manual%20Rev%201.docx