ICP Prior Authorization Form

Instructions:

Please validate patient eligibility and benefits prior to rendering services
Submit all clinical documentation such as progress notes/labs/radiology with requests
For questions, please call the Medical Management Department at (800) 250-6647 or (480) 400-0027

Payment for services is dependent upon the patient's eligibility at the time services are rendered. Copays, coinsurance and/or deductibles may apply. Pre-certifications are valid for the date range specified on this form.

Click to download PDF version

Please fill out all fields with *

Request Type

Please select your type of request from the dropdown.

Authorization Processing Time

Routine/Standard Request:Urgent Request:

INPATIENT CONCURRENT (IP/Obs)	Decision will be rendered within 24 hours from receipt of all necessary information.
URGENT* PRESERVICE	Decision will be rendered within 72 hours from receipt of all necessary information.
PRESERVICE (Routine)	Decision will be rendered within 15 calendar days from receipt of all necessary information.
POST SERVICE (Retro)	Decision will be rendered within 30 calendar days from receipt of all necessary information. [Post Service (Retro) requests are accepted up to 12 months from the date of service.]

*Urgent requests apply when: The PreService (routine) time frame could seriously jeopardize the life, health or ability to regain maximum function or subject the member to severe pain that cannot be managed without requested treatment.

Patient Information

Eligibility Verified?*

YesNo

Future date is not available

Validation failed. Need 3 to 8 digits followed by SLHN in uppercase

Please fill out this field.

Servicing Provider Information

Provider Type?

PhysicianPracticeFacilityVendor

Facility/Company Information

Address same as servicing provider

In NetworkOut of Network

Diagnosis Code	Diagnosis

Please fill out primary field.

Procedure Code	Procedure or Equipment	Units

Please fill out primary field.

Available special characters are . , - / and space.

Attachments

*Attachment(s) is required

Please submit all supporting clinical documentation with request.

*Max file size is 10MB.

Upload

HIPAA Notice: The information contained in this form may be confidential and legally privileged information. It is only for the use of individual or entity named above. If the recipient of this form is not the recipient addressed on the form, you are hereby notified that any dissemination, distribution or copying of the attached document(s) is strictly prohibited. If you have received this in error, please immediately notify the sender by telephone and return the form to the sender.

Org. 11/17 Rev.

Clear Form