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 TELLIGEN VIA QUALITRAC: (STAMP HERE) SECTION V Specific Preauthorization Information – Patient Location: Home Nursing Home Hospital In-Patient Discharge Date Address where equipment will be used (if different from above): Period of time requested: MFGR MODEL/PRODUCT SINGLE UNIT AMT. PKG NUMBER PRICE $ $ $ $ $
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 TELLIGEN VIA QUALITRAC: (STAMP HERE) SECTION V – Specific Preauthorization Information Patient Location: Home Nursing Home Hospital In-Patient Discharge Date Address where equipment will be used (if different from above): Period of time requested: MFGR MODEL/PRODUCT NUMBER SINGLE UNIT PRICE AMT. PKG $ $ $ $ $
Audiology,%20Physical%20Therapy,%20and%20EPSDT%20Provider%20Manual%206%2021%2018.docx