Community Health Group | Add or change CPT codes in existing authorization

Font Size

Add or Change CPT Codes in Existing Authorization

Issue Statement:

Authorization #:

Member Name:

CHG ID #:

CPT Code:

Multiple CPT codes will be separated by commas. The format will be "99000, 99001, 99002"

Total Units:

CPT Code:

Multiple CPT codes will be separated by commas. The format will be "99000= 99001, 99001= 99002"

Total Units:

CPT Code:

Multiple CPT codes will be separated by commas. The format will be "99000, 99001, 99002"

Total Units:

CPT Code:

Multiple CPT codes will be separated by commas. The format will be "99000= 99001, 99001= 99002"

Total Units:

Medical Reason for the Request:

Have Services Been Rendered?

Name:

Phone #:

Email Address:

File(s):

Add another