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How to use or fill out PRIOR AUTHORIZATION for ANESTHESIA SERVICES
- Click ‘Get Form’ to open it in the editor.
- Begin with Section I: PATIENT INFORMATION. Fill in the patient's name, date of birth, age, and PEHP ID number accurately.
- Proceed to Section II: PROVIDER INFORMATION. Enter the date requested, ordering provider's details including contact person, NPI number, and phone/fax numbers.
- In Section III: PRE-AUTHORIZATION REQUEST, specify the requested dates of service and select the nature of request (e.g., Pre-Authorization).
- Indicate the primary diagnosis using ICD-10 codes and select the type of anesthesia requested from the provided options.
- Complete additional fields regarding place of service, estimated anesthesia time, and list all requested procedures with corresponding CPT/HCPCS codes.
- Finally, review your entries for accuracy before submitting. Ensure all necessary patient chart notes are included.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2025 | 4.6 Satisfied (36 Votes) | |
| 2024 | 4.8 Satisfied (57 Votes) | |
| 2024 | 4.5 Satisfied (54 Votes) | |
| 2024 | 4.6 Satisfied (24 Votes) | |
| 2024 | 4.2 Satisfied (22 Votes) | |
| 2024 | 4.9 Satisfied (39 Votes) | |
| 2023 | 4.6 Satisfied (29 Votes) | |
| 2023 | 4.2 Satisfied (33 Votes) | |
| 2023 | 4.8 Satisfied (51 Votes) | |
| 2023 | 4.3 Satisfied (30 Votes) | |
| 2023 | 4.4 Satisfied (43 Votes) | |
| 2023 | 4.1 Satisfied (50 Votes) | |
| 2023 | 4.8 Satisfied (43 Votes) | |
| 2023 | 4.3 Satisfied (48 Votes) | |
| 2022 | 4.8 Satisfied (52 Votes) |
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