Diagnostic Imaging
Pre-Authorizations

Simple and Secure

We're your quick and easy solution for diagnostic imaging patient pre-authorizations. Please be sure to fill out the form completely and accurately for the quickest result.

Call us: (833) PRE-AUTH
Email us: info@outpatientbenefits.com

Patient Pre-Authorization Form

Patient Information

First Name:

MI:

Last Name:

Suffix:

Date of Birth:

Gender:

Patient Cell/Home Phone #:

Patient ID, MRN, Ref # (Optional):

Last 4 Digits SSN:

Insurance Information

Insurance Company:

Policy Number:

Group Number:

Procedure Information

NPI - Ordering Physician:

First Name - Ordering Physician:

Last Name - Ordering Physician:

NPI - Service Facility:

Name - Service Facility:

Location - Service Facility:

Tax ID - Service Facility:

Procedure Code:

Diagnosis (ICD-10):

Date Scheduled:

Billed Charges: $

+ Add Procedure (CPT)

Requesting Party First Name:

Requesting Party Last Name:

Requesting Party Email (Authorizations will be sent to the email provided):

Diagnostic ImagingPre-Authorizations

Patient Pre-Authorization Form

Diagnostic Imaging
Pre-Authorizations