Texas Standard Prior Authorization Request Form

Practice Manager **Texas Authorization Request Form for Health Care Services** **Provider Information:** * **Name:** Dr. Emily Carter * **NPI:** 1234567890 * **Tax ID:** 98-7654321 * **Address:** 456 Oak Avenue, Austin, TX 78701 * **Phone:** (512) 555-1234 * **Fax:** (512) 555-5678 **Patient Information:** * **Name:** Sarah Johnson * **Date of Birth:** 15 May 1990 * **Insurance ID:** SJ90123456 * **Group Number (if applicable):** TXGRP789 * **Address:** 789 Pine Street, Austin, TX 78702 * **Phone:** (512) 555-9876 **Requested Service Information:** * **Service/Procedure Code (CPT/HCPCS):** 99203 (New Patient Office Visit, Moderate Complexity) * **Diagnosis Code (ICD-10):** R51 (Headache) * **Date of Service (or range):** 1 November 2024 * **Facility (if applicable):** Austin Family Clinic * **Service Location:** Outpatient Clinic * **Reason for Request/Medical Necessity:** Patient presents with chronic tension headaches, increasing in frequency and severity over the past three months, impacting daily activities. Initial evaluation and development of a treatment plan are required. * **Prior Authorisation Number (if resubmission):** N/A **Referring Provider Information (if applicable):** * **Name:** Dr. Michael Green * **NPI:** 0987654321 * **Address:** 101 Elm Street, Austin, TX 78701 * **Phone:** (512) 555-4321 **Authorization Request Details:** * **Type of Request:** Initial * **Is this an urgent request?** No * **If urgent, state medical justification:** N/A * **Attach supporting clinical documentation (e.g., progress notes, lab results, imaging reports):** Attached are initial consultation notes from Dr. Green and patient's symptom diary. **Signature:** * **Provider/Authorised Representative:** Dr. Emily Carter * **Date:** 1 November 2024