1) Date of Request: / / 2) Initial Review Recertification Retro Authorization Change 3) Service Type: 2) Start Date requested: / / 3) Expected Discharge Date: / / PRTF 4) DOB (mm/dd/yyyy): / / Requesting retroactive authorization: Yes No 5) Member Last Name: 6) Member First Name: 7) Member Medicaid ID #: 8) Gender: 9) Referring Provider 10a.) Servicing Provider Name/ NPI #: 10b.) Servicing Provider Address/ Male Name/NPI #: Zip Code: Female 11) Provider Contact Person: 12) Provider Phone #: 13) Provider Fax #:
1) Date of Request: / / 2) Initial Review Recertification Retro Authorization Change 3) Service Type: PRTF 2) Start Date requested: / / 3) Expected Discharge Date: / / 4) DOB (mm/dd/yyyy): / / Requesting retroactive authorization: Yes No 5) Member Last Name: 6) Member First Name: 7) Member Medicaid ID #: 8) Gender: Male Female 9) Referring Provider Name/NPI #: 10a.) Servicing Provider Name/ NPI #: 10b.) Servicing Provider Address/ Zip Code: 11) Provider Contact Person: 12) Provider Phone #: 13) Provider Fax #:
SCPRTFFaxFormapproved.docx