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Prior Authorization Level 3 (PA-3) Request Form
Submission Instructions: Please complete this form and other sections as appropriate and send it to the World
Trade Center Health Program by posting it to the secure SFTP server and then sending an email to
[email protected] indicating the secure server posting of this request. Incomplete forms will be sent back for
more information. Not to be used for dental or transplant requests. DO NOT FILL OUT NIOSH DECISION OR
NIOSH DECISION RATIONALE.
General and Member Information
Request Date
Member Type
Responder
Member Name
Member Date of Birth
Survivor
Choose a CCE/NPN
Member 911#
Relevant Certified Condition
ICD Code
Relevant Certified Condition
ICD Code
Relevant Certified Condition
ICD Code
CCE/NPN Requester Information
Requester Name
Requester Credentials
Requester E-mail
Requester Phone
Clinical Director Name (if not requester)
Clinical Director Concurrence Signature
Standard Authorization Request (Non Dental)
Procedure/Service
NIOSH Decision
CPT Code
NIOSH Decision Rationale
Procedure/Service
NIOSH Decision
CPT Code
NIOSH Decision Rationale
Procedure/Service
NIOSH Decision
CPT Code
NIOSH Decision Rationale
Procedure/Service
NIOSH Decision
CPT Code
NIOSH Decision Rationale
Procedure/Service
NIOSH Decision
CPT Code
NIOSH Decision Rationale
Clinical Summary Please describe the type of procedure(s)/service(s) requested above. Please provide
medical necessity rationale describing how they relate(s) to the treatment or management of the certified WTCrelated condition or medically associated condition. Treatment must be non-experimental and noninvestigational . Document any other designated criteria noted in the WTCHP Codebook guidelines for the
procedure(s)/service(s), WTCHP Policy and Procedures Manual or WTCHP Codebook guidelines.
TO BE FILLED OUT BY A NIOSH
Name
NIOSH Decision
NIOSH Decision Comments
Credentials
Signature
File Type | application/pdf |
File Modified | 2015-08-20 |
File Created | 2015-08-20 |