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OBTAIN REFERRALS & TREATMENT AUTHORIZATION REQUEST PATIENT INFORMATION Date Patient Name Phone Number M DOB REQUESTING PHYSICIAN INFORMATION Primary Care Physician Phone Number Provider Number REQUESTED SERVICE Select service to be performed: O Ambulatory Surgery/Procedure O Inpatient Services Cardiac Rehabilitation O Pain Management Medications Durable Medical Equipment Biofeedback MRI O Non-participating Provider O Physical/Occupational Therapy Surgery/procedure/supply/med requested Facility where service is to be performed Facility Address Phone Number Facility City, State, Zip Estimated length of stay Procedure Code: Description: Procedure Code: Description: Diagnosis Code: Description: Diagnosis Code: Description: Signature of Requesting Physician: Date: O OOO

OBTAIN REFERRALS & TREATMENT AUTHORIZATION REQUEST PATIENT INFORMATION Date Patient Name Phone Number M DOB REQUESTING PHYSICIAN INFORMATION Primary Care Physician Phone Number Provider Number REQUESTED SERVICE Select service to be performed: O Ambulatory Surgery/Procedure O Inpatient Services Cardiac Rehabilitation O Pain Management Medications Durable Medical Equipment Biofeedback MRI O Non-participating Provider O Physical/Occupational Therapy Surgery/procedure/supply/med requested Facility where service is to be performed Facility Address Phone Number Facility City, State, Zip Estimated length of stay Procedure Code: Description: Procedure Code: Description: Diagnosis Code: Description: Diagnosis Code: Description: Signature of Requesting Physician: Date: O OOO

Phlebotomy Essentials
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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Competency Assessment Information: Use the following information to complete the Treatment Authorization Request Scenario: Dr. King has ordered an MRI of the knee for Roberto Benini to confirm a diagnosis of osteomyelitis. The MRI will be done at Northborough Advanced Imaging. The patient is insured through Aetna, which requires preauthorization for this procedure Patient Demographics: Name: Roberto Benini Phone # (123) 555-1212 Address: 77 Treelawn Place Northborough, XY 12345 DOB: 12/05/1965 Referring Facility: Northborough Advanced Imaging Phone # (123) 555-8900 Address: 1500 Broadway Boulevard Northborough, XY 12345 Clinic: Dr. Mark King, NPI 9995020212 Phone # (123) 456-7890 Address: 8600 Main Street, Suite 200, River City, XY 01234
Transcribed Image Text:Competency Assessment Information: Use the following information to complete the Treatment Authorization Request Scenario: Dr. King has ordered an MRI of the knee for Roberto Benini to confirm a diagnosis of osteomyelitis. The MRI will be done at Northborough Advanced Imaging. The patient is insured through Aetna, which requires preauthorization for this procedure Patient Demographics: Name: Roberto Benini Phone # (123) 555-1212 Address: 77 Treelawn Place Northborough, XY 12345 DOB: 12/05/1965 Referring Facility: Northborough Advanced Imaging Phone # (123) 555-8900 Address: 1500 Broadway Boulevard Northborough, XY 12345 Clinic: Dr. Mark King, NPI 9995020212 Phone # (123) 456-7890 Address: 8600 Main Street, Suite 200, River City, XY 01234
OBTAIN REFERRALS & TREATMENT AUTHORIZATION REQUEST PATIENT INFORMATION Date Patient Name Phone Number F DOB REQUESTING PHYSICIAN INFORMATION Primary Care Physician Provider Number Phone Number REQUESTED SERVICE Select service to be performed: OAmbulatory Surgery/Procedure O Inpatient Services Cardiac Rehabilitation Pain Management Medications Durable Medical Equipment Biofeedback MRI O Non-participating Provider O Physical/Occupational Therapy Surgery/procedure/supply/med requested Facility where service is to be performed Facility Address Phone Number Facility City, State, Zip Estimated length of stay Procedure Code: Description: Procedure Code: Description: Diagnosis Code: Description: Diagnosis Code: Description: Signature of Requesting Physician: Date: TO BE COMPLETED BY UTILIZATION MANAGEMENT Authorized Not authorized Deferred Authorization Request # Comments Modified
Transcribed Image Text:OBTAIN REFERRALS & TREATMENT AUTHORIZATION REQUEST PATIENT INFORMATION Date Patient Name Phone Number F DOB REQUESTING PHYSICIAN INFORMATION Primary Care Physician Provider Number Phone Number REQUESTED SERVICE Select service to be performed: OAmbulatory Surgery/Procedure O Inpatient Services Cardiac Rehabilitation Pain Management Medications Durable Medical Equipment Biofeedback MRI O Non-participating Provider O Physical/Occupational Therapy Surgery/procedure/supply/med requested Facility where service is to be performed Facility Address Phone Number Facility City, State, Zip Estimated length of stay Procedure Code: Description: Procedure Code: Description: Diagnosis Code: Description: Diagnosis Code: Description: Signature of Requesting Physician: Date: TO BE COMPLETED BY UTILIZATION MANAGEMENT Authorized Not authorized Deferred Authorization Request # Comments Modified
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