MANAGED CARE PLAN
TREATMENT AUTHORIZATION REQUEST
TO BE COMPLETED BY
PRIMARY CARE PHYSICIAN
OR OUTSIDE PROVIDER
Health Net
Met Life
Pacificare
Travelers
Secure Horizons
Pru Care
Patient Name _______________________________Date_______________________________
M__F__ Birthdate_______________________Home Telephone Number___________________
Address______________________________________________________________________
Primary Care Physician_____________________________________ Member ID#__________
Referring Physician________________________________________ Member ID#__________
Referred to________________________________ Address_____________________
_______________________________ Office Telephone No_____________
Diagnosis Code________ Diagnosis________________________________________________
Diagnosis Code________ Diagnosis________________________________________________
Treatment Plan _________________________________________________________________
Authorization requested for procedures/tests/visits:
Procedure Code________ Procedure________________________________________________
Procedure Code________ Procedure________________________________________________
Facility to be used__________________ Estimated length of stay ________________________
Office
Outpatient
Inpatient
Other
List of potential consultants (e.g. anesthetists, assistants, or medical/surgical):
_____________________________________________________________________________
Physician’s signature ____________________________________________________________
TO BE COMPLETED BY PRIMARY CARE PHYSICIAN
PCP Recommendations__________________________________________ PCP Initials______
Eligibility checked__________________________ Effective Date________________________
TO BE COMPLETED BY UTILIZATION MANAGEMENT
Authorized______________________ Not Authorized__________________
Deferred________________________ Modified________________________
Authorization Request #__________________________________________
Comments_________________________________________________________