Cataract Surgery Pre-Authorization Request Form

Cataract Surgery Pre-Authorization Request Form
Use this form to submit patient, insurance, provider, and clinical details needed to request pre-authorization for cataract surgery.
Patient Information
Patient Full Name
First NameMiddle NameLast Name
Date of Birth
MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Insurance and Coverage Information
Insurance Provider Name
Member / Subscriber Name
First NameMiddle NameLast Name
Member ID
Group Number
Plan Type
Policyholder Relationship to Patient
Other
Referring Provider and Facility Details
Referring Provider Name
First NameMiddle NameLast Name
Practice / Clinic Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number or Secure Contact Method
NPI (if applicable)
Requestor / Facility Name
Clinical Diagnosis and Procedure Request
Diagnosis
Eye Affected
Other
Procedure Requested
Urgency Level
ICD Code(s)
Medical Necessity Statement
Surgery Scheduling Details
Preferred Surgery Date
MonthDayYear
Date
Surgery Facility / Location
Surgeon Name
First NameLast Name
Scheduling Constraints or Notes
Pre-Authorization Documentation and Notes
Supporting Documentation Checklist
Upload Supporting Documents
Cancelof
Additional Notes for Insurer
Should be Empty: