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RMHP Prior Authorization List Effective October 1, 2017 V5 Revised

RMHP Prior Authorization List Effective October 1, 2017 V5 Revised-2025

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The document is a request form for lumbar spine fusion (LSF) procedures, detailing the necessary information required from the ordering provider and patient. It includes sections for patient demographics, medical history, diagnosis, previous treatments, imaging studies, and clinical information relevant to the surgical request. The form emphasizes the importance of providing complete and accurate information to avoid delays in processing and outlines submission methods for both urgent and non-urgent requests.

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