Modify Existing Prior Authorization

This form should be used only if you submitted a prior authorization that was previously approved.

**Disclaimer: This request will not be processed without all information.

Group Number
Member ID
Patient Name Patient Name First Last
Previously Approved Prior Authorization Number
Reason for modification

Reason for modification Date of service change Site of service change Change or add Diagnosis code Change or add CPT code Other Other
Treatment Start Date Treatment Start Date / MM / DD YYYY
Treatment End Date Treatment End Date / MM / DD YYYY
Site of Service Name
Site of Service Address Site of Service Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Site of Service Tax ID
Diagnosis code
Diagnosis
Procedure code
Procedure
Name of person submitting prior authorization modification Name of person submitting prior authorization modification First Last
Phone of person submitting prior authorization modification Phone of person submitting prior authorization modification - ### - ### ####
Fax of person submitting prior authorization modification Fax of person submitting prior authorization modification - ### - ### ####
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