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Please check type of request: ___________ expedited (medicare only—care required within 72. Web prior authorization request form. Please fill out all applicable sections on both pages. Ambulance transports, non emergent (request submitted for review with.

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Please check type of request: Web prior authorization request form. Fill out the member appeal request form. Web for more detailed information, consult the provider operations manual, available on the affinity provider portal. Web affinity.

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Ambulance transports, non emergent (request submitted for review with key information) bariatric services and surgery; Please check type of request: Please check type of request: ___________ expedited (medicare only—care required within 72.

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Web frequently used forms. Please check type of request: This form must be accompanied by all clinical information which includes prescription results of physical exam, diagnostic tests, lab test results, functional problems, presenting symptoms and treatment plan. Please check type of request: Web prior authorization request form.