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Authorization Review Form for Health Care Services BEHAVIORAL HEALTH SERVICES Pre-Authorization OP IP Fax: 713 576 0939 Providers must submit the Prior Authorization Request Form The form must include the following information:
City Ambulance Service If a patient does not meet the medical necessity requirements for ambulance transportation, consider alternative options such as a wheelchair van, taxi, rideshare services like Uber, or assistance from friends and family
OUTPATIENT Prior Authorization Fax Form - cityambu. com Prior Authorization Fax Form Fax to: 855-537-3447 Request for additional units Existing Authorization Units Standard and Urgent Pre-Service Requests - Determination within 3 calendar days (72 hours) of receiving the request * INDICATES REQUIRED FIELD