PA-2025-001
Review & Submit
Step 8 of 8
Review all information carefully before submitting your prior authorization request. Once submitted, modifications will require a new request.
Patient Information
Full Name:
Smith, Janice
Date of Birth:
April 30, 1970
MRN Number:
12345
Phone Number:
(760) 937-5480
Address:
2230 Hessler Blvd
New Castle, DE 19720
Photo ID:
Primary Insurance Coverage
Insurance Plan:
Blue Cross Blue Shield
Member ID:
BC987654321
Eligibility:
Verified
Verification Method:
Payor portal
Insurance Card:
Ordering Provider
Provider Name:
Dr. Michael Chen
NPI Number:
0987654321
Specialty:
Pulmonology
Contact:
mchen@pulmocare.com
TIN:
12-3456789
PTAN:
0012345
Facility Information
Facility Name:
Beebe Healthcare
Facility NPI:
0012345
TIN:
12-3456789
Address:
424 Savannah Rd
Lewes, DE 19958
Device/Service
HCPCS/CPT Code:
E0470
Device Model:
ResMed AirSense 10
Manufacturer:
ResMed
Place of Service:
Home
Request Urgency:
Routine
Diagnosis Codes
Primary ICD-10 Code:
G47.33
Secondary ICD-10 Codes:
N/A
Ready for Clinician Signature
By signing, you confirm that all information is accurate and complete. This prior authorization request will be transmitted to the payer via their online Portal.