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Prior Authorization Forms

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Form Description Last Revision Date
NF_Ancillary_PA_Form January 2021
Prior Authorization Checklist June 2019
Radiology Codes Sept. 2006
Independent Therapy Request Form June 2023
Instructions for Independent Therapy Request Form
Obstetric Notification Form Dec. 2009
MAP 5 EPSDT Dental Evaluation Form
March 2008
MAP 9 Prior Authorization for Health Services
April 2021
MAP 9A Orthodonitc Services Agreement June 2005
MAP 130 PA Fax Form Sept. 2011
MAP 249 MAP 249 PDN Clinical Review April 2014
MAP 306 Temporomandibular Joint (TMJ) Assessment June 2005
MAP 396 Orthodontic Evaluation June 2005
MAP 556 Orthodontic Referral June 2005
MAP 559 Six Month Orthodontic Progress June 2005
MAP 569 Psychiatric Preadmission Review of Elective Admissions June 2005
MAP 570 Certification of Need for Inpatient Psychiatric Svcs for Individuals under Age 21 June 2005
MAP 575 Request for Reconsideration of Resources Utilization Group Audit Determination June 2005
Map 576 Nurse Aide Training Expense Report and Authorization for Payment July 2012
MAP 650 Home Health Fax Form March 2021
MAP 700 Orthodontic Final Case Submission June 2005
MAP 703 Request for Reconsideration Ancillary Therapy Billing March 2014
MAP 726A Nursing Facility Request for Admission Sept. 2003
MAP 1000 Certificate of Medical Necessity - Durable Medical Equipment July 2010
MAP 1000B Certificate of Medical Necessity - Metabolic Formulas & Foods July 2010

Last Updated 5/15/2019 
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