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Eastern Oregon Coordinated Care Organization
Patient Information
Patient Name____________________________________________ DOB _________________
OHP Client ID # ____________________________ Group # ______________
PCP/On Call Doctor Information
PCP/On Call Doctor ___________________________________TIN # ______________________________________
Ph#_______________________________Fax # _____________________________Contact ____________________
Specialist Information
Specialist Name ______________________________ TIN# ______________________________________________
Ph#_______________________________Fax# ____________________________Contact ______________________
Address/Location_______________________________________________________________________________
Facility Information
Facility ______________________________________________TIN #_____________________________________
Ph # ______________________________ Fax#____________________________Contact _____________________
Admit Date_____________________Discharge Date_____________________
Additional authorization/referral information
ICD10 code(s)_______ _______ _______ _______ _______HCPC code(s)_______ _______ _______ _______ _______
Comments:
For EOCCO use only: Authorization Number _____________________________Denial Number___________________________
Referral and Authorization
CPT code(s) _______ _______ _______ _______ _______ _______ _______ _______
Date span requested _________________ to _________________ #of visits/Inpt nights requested__________
Is this for a second opinion Yes No
(503) 243-4496 (800) 258-2037 Fax (833) 949-1886PO Box 40384 Portland, OR 97240
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* = Required Information
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Are you referring to an Out of Network Provider? Yes No
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If Yes, I attest this is the only Provider who can treat this condition
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RUSH (ONLY for cases in which a Provider indicates that following the standard time frame could seriously jeopardize the members life or health or ability to attain, maintain or regain maximum function
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Outpatient