Nivano Physicians Authorization Form - Fill Online 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'General Information' section. Enter the patient's name, date of birth, address, city, state, zip code, member ID number, subscriber name, and primary care provider (PCP).
3. In the 'Referrals' section, select the type of request: Urgent, Routine, Appeal, or others as applicable. If you are updating a decisioned authorization or need a retroactive date of service (DOS), provide those details.
4. Complete the 'Services Requested' section by indicating whether it's a new consult or follow-up visit. Include diagnosis ICD 10 codes and CPT codes along with quantities for each service requested.
5. Attach any necessary documentation such as consultation notes or x-ray reports to support medical necessity before submitting your form.

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