Hiive Health

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PA-2025-001

Archive Case

Archive Case

Case Progress

Patient Information

Provider Information

Device/Service Details

Clinical Information

Policy Review

Quality Assurance

Letter of Medical Necessity

Review & Submit

Case Progress

Patient Information

Provider Information

Device/Service Details

Clinical Information

Policy Review

Quality Assurance

Letter of Medical Necessity

Review & Submit

Patient Information

Step 1 of 8

Please provide complete patient demographic and insurance information for the prior authorization request.

Patient Information

Full Name *

Date of Birth *

Medical Record Number (MRN) *

Phone Number

Photo ID (Front) *

Click or drag to upload. Max 25 MB

Photo ID (Back) *

Click or drag to upload. Max 25 MB

Primary Insurance Coverage

Insurance Plan *

Member ID *

Verification Method

Eligibility Verification

Eligibility Verified

Insurance Card (Front) *

Click or drag to upload. Max 25 MB

Insurance Card (Back) *

Click or drag to upload. Max 25 MB

Secondary Insurance Coverage (optional)

Insurance Plan *

Member ID *

Verification Method

Eligibility Verification

Eligibility Verified

Insurance Card (Front) *

Click or drag to upload. Max 25 MB

Insurance Card (Back) *

Click or drag to upload. Max 25 MB

Address Information

Address Line 1

Address Line 2

City

State.

Zip

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Continue to provider information