netWell Pre-Authorization Request Form
Section I: Submission
Requestor Name*
Phone*
Fax*
Requestor Location*
Section II: General Information
Review Type*
Request Type*
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*
Zip*
Service Provider or Facility
Name*
Tax ID*
Phone*
Fax*
Address 1*
Address 2*
City*
State*
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*
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