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22 11/2005
Phone: (800) 722-6614 Atlanta - HMO/ POS Fax: (404) 842-8390 Outside of Atlanta (888) 246-0226
Columbus - PPO, Indemnity Fax: (877) 254-4971
PRECERTIFICATION FORM FOR PROCEDURES AND DIAGNOSTICS
This form is to be used for HMO, POS, PPO and indemnity products. An authorization Number will be faxed back upon approval.
Patient Name:___________________________________DOB: _______________________________________
ID Number:__________________________HMO:________POS:_______PPO:___________________________
Ordering MD:_________________________________________________________________________________
Phone #: ____________________ Contact Person: ___________________________ Fax #:________________
Diagnosis:__________ Code:__________________ Date of
Procedure:_________________________________
Procedures:________ CPT Codes:_____________ Facility:____________________________________
___________________ _______________ Outpatient: ________________________________
___________________ ________________ Inpatient: _________________________________
Check one if using: Physician Assistant Assistant Surgeon
Clinical (i.e. s/s, physical exam findings, diagnostic testing, labs): ______________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
(Sleep Study Requests: If over age 14 yrs, please include height, weight, & BP, Epworth Sleepiness Scale)
Conservative Treatment (include medications/length of time taken):
___________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Response to Treatment: ________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Note: Please include any pertinent office notes/tests or lab results. All information should be written legibly or typed.
All medically stat or urgent requests should be called to (800) 722-6614. You are advised to verify benefits. Authorization
is based on medical necessity only & is not a guarantee of payment.
BlueChoice Healthcare Plan, BlueChoice Option are underwritten by Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.
Blue Choice PPO is underwritten by Blue Cross and Blue Shield of Georgia, Inc.
Independent licensees of the Blue Cross and Blue Shield Association.