netWell Pre-Authorization Request Form
Section I: Submission
Requestor Name
*
Phone
*
Fax
*
Requestor Location
*
Section II: General Information
Review Type
*
Select an option
Non-Urgent
Urgent
Request Type
*
Select an option
Initial Request
Extenstion / Renewal / Amendment
Section III: Patient Information
Patient First Name
*
Patient Last Name
*
Patient Date of Birth
*
Primary First Name
*
Primary Last Name
*
Primary Member ID
*
Section IV: Provider Information
Requesting Provider
First Name
*
Last Name
*
Provider Title
*
Tax ID
*
Phone
*
Fax
*
Address 1
*
Address 2
*
City
*
State
*
Select State
AL - ALABAMA
AK - ALASKA
AZ - ARIZONA
AR - ARKANSAS
CA - CALIFORNIA
CO - COLORADO
CT - CONNECTICUT
DE - DELEWARE
DC - DISTRICT OF COLUMBIA
FL - FLORIDA
GA - GEORGIA
HI - HAWAII
ID - IDAHO
IL - ILLINOIS
IN - INDIANA
IA - IOWA
KS - KANSAS
KY - KENTUCKY
LA - LOUISIANA
ME - MAINE
MD - MARYLAND
MA - MASSACHUSETTS
MI - MICHIGAN
MN - MINNISOTA
MS - MISSISSIPPI
MO - MISSOURI
MT - MONTANA
NE - NEBRASKA
NY - NEVADA
NH - NEW HAMPSHIRE
NH - NEW JERSEY
NM - NEW MEXICO
NY - NEW YORK
NC - NORTH CAROLINA
ND - NORTH DAKOTA
OH - OHIO
OK - OKLAHOMA
OR - OREGON
RI - RHODE ISLAND
SC - SOUTH CAROLINA
SD - SOUTH DAKOTA
TN - TENNESSEE
TX - TEXAS
UT - UTAH
VT - VERMONT
VA - VIRGINIA
WA - WASHINGTON
WV - WEST VIRGINIA
WI - WISCONSIN
WY - WYOIMING
Zip
*
Service Provider or Facility
Name
*
Tax ID
*
Phone
*
Fax
*
Address 1
*
Address 2
*
City
*
State
*
Select State
AL - ALABAMA
AK - ALASKA
AZ - ARIZONA
AR - ARKANSAS
CA - CALIFORNIA
CO - COLORADO
CT - CONNECTICUT
DE - DELEWARE
DC - DISTRICT OF COLUMBIA
FL - FLORIDA
GA - GEORGIA
HI - HAWAII
ID - IDAHO
IL - ILLINOIS
IN - INDIANA
IA - IOWA
KS - KANSAS
KY - KENTUCKY
LA - LOUISIANA
ME - MAINE
MD - MARYLAND
MA - MASSACHUSETTS
MI - MICHIGAN
MN - MINNISOTA
MS - MISSISSIPPI
MO - MISSOURI
MT - MONTANA
NE - NEBRASKA
NY - NEVADA
NH - NEW HAMPSHIRE
NH - NEW JERSEY
NM - NEW MEXICO
NY - NEW YORK
NC - NORTH CAROLINA
ND - NORTH DAKOTA
OH - OHIO
OK - OKLAHOMA
OR - OREGON
RI - RHODE ISLAND
SC - SOUTH CAROLINA
SD - SOUTH DAKOTA
TN - TENNESSEE
TX - TEXAS
UT - UTAH
VT - VERMONT
VA - VIRGINIA
WA - WASHINGTON
WV - WEST VIRGINIA
WI - WISCONSIN
WY - WYOIMING
Zip
*
Section V: Services Requested
Diagnosis (Description)
*
ICD-10 Code
*
Planned Service Or Procedure (CPT / HCPC Description)
Code
*
Planned Service Or Procedure (CPT / HCPC Description)
Code
Planned Service Or Procedure (CPT / HCPC Description)
Code
Planned Service Or Procedure (CPT / HCPC Description)
Code
Planned Service Or Procedure (CPT / HCPC Description)
Code
Date of Service Start
*
Date of Service End
*
Estimated Cost of Planned Service or Procedure
*
ESTIMATES OR ESTIMATES EQUALING $0 WILL BE DENIED
Service Location
*
Select an option
Inpatient Procedure or Hospitalization
Outpatient Procedure or Hospitalization
Provider Office
Observation
Is this a therapeutic service
*
Yes
No
Section VI: Clinical Documentation
Please add any additional details you would like us to know about here
Please provide the last two years of medical records
Choose Or Drop Files
Submit
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