Previous Authorization Number: 2026

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4.4 out of 5

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The document is an AK Secondary Authorization Request (SAR) form used to collect patient and provider information for requesting prior authorization of medical services. It includes sections for patient details, requesting provider information, type of care requested, clinical information, and discharge needs. The form emphasizes the need for supporting documentation to ensure timely review by the Anchorage VA Medical Center.

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Click ‘Get Form’ to open the Previous Authorization Number: in the editor.
Begin with SECTION I: PATIENT INFORMATION. Fill in the patient's last name, first name, address, date of birth (DOB), city, state, and zip code.
Move to SECTION II: REQUESTING PROVIDER INFORMATION. Enter details such as the requesting provider's name, contact person, TIN, phone number, address, fax number, specialty type, group name, and select whether the request is routine or urgent.
In SECTION III: TYPE OF CARE REQUEST, provide the diagnosis using ICD 10 codes and describe the requested service including CPT/HCPCS codes. Indicate if this is a referral to another specialty and fill out servicing provider information if applicable.
Proceed to SECTION IV: TYPE OF SERVICES REQUESTED. Specify services like PT, OT, speech therapy or surgical procedures along with frequency and duration.
Complete SECTION V: CLINICAL INFORMATION by attaching necessary documentation that supports medical necessity for services requested.
Finally, if applicable, fill out SECTION VI: DISCHARGE NEEDS for inpatient admissions or procedures detailing any additional needs.

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Versions	Form popularity	Fillable & printable
2017	4.4 Satisfied (33 Votes)
2016	4.7 Satisfied (29 Votes)

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Prior authorization requires your doctor or provider to obtain approval from your health plan before providing health care services or prescribing prescription drugs. Without prior authorization, your health plan may not pay for your treatment or medication. (Emergency care doesnt need prior authorization.)

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The drivers license number (near the top of the license) looks like it is staying the same. The serial number (at the bottom of the license) might be changing).