First Name: Middle Initial: Last Name:
DOB (mm/dd/yyyy ):
Gender: Male Female
Street Address: Apt #:
City: State: Zip:
Primary Contact:
Home Cell
Health Plan: Member ID: Group ID:
Physician Phone: Physician Fax:
Office Contact: Ext:
Contact Email:
Group/Site Name:
Primary Specialty:
Diagnosis, if known or rule out:
ICD-10 Codes:
Date of last visit:
Page 1 of 2
Authorization Fax Form
List all
applicable
CPT codes
and modifiers:
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request. ationzauthori an submit to site
the on located portal provider the into log also may You section. Forms Fax and Guidelines the under eviCore.com
on found be can numbers fax and
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