Medicare Radiology Prior Authorization Request

Medicare Radiology Prior Authorization Request
Submit details to request prior authorization for radiology procedures under Medicare.
Patient Full Name
First NameLast Name
Patient Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Medicare Insurance ID
Referring Provider Name
First NameLast Name
Referring Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Ordering Facility Name
Ordering Facility Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Requested Radiology Procedure
CPT Code(s) for Requested Procedure
Body Part to be Examined
Clinical Indication / Reason for Exam
Has the patient had prior relevant imaging for this condition?
If yes, please specify type and date of prior imaging
Requested Date of Service
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Email for Authorization Updates
example@example.com
I authorize the release of medical information necessary to process this prior authorization request for radiology services. I confirm that the information provided is accurate to the best of my knowledge.
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