Avant Health Prior Auth Submission Form

Complete all required fields to submit your prior authorization request. You can contact us at provider@avanthealth.ai or 469.249.9072. Approval of prior auth confirms medical necessity but doesn't guarantee payment.

Patient Name

Patient Date of Birth

Your answer

Gender

Female
Male

Patient Phone

Patient Email Address

Insurance Member ID

Group ID

Requesting Provider Name

Provider Specialty

Provider Credentials

NPI

License

Tax ID Number

Provider Phone Number

Email for PA Decision

Important! This is where the PA decision will be sent.

Practice Facility Name

Practice Mailing Address

Description of Requested Procedure/Service

ICD-10 Codes

Please list all relevant codes separated by commas.

CPT Codes

Enter N/A for codes that don’t apply. Cannot leave CPT AND HCPCS both blank.
Please list all relevant codes separated by commas.

HCPCS Codes

Enter N/A for codes that don’t apply. Cannot leave CPT AND HCPCS both blank.
Please list all relevant codes separated by commas.

Request Type

routine
urgent
concurrent
post-service (must be within 90 days of service)

Office Contact Person

Office Contact Phone Number

Office Contact Fax Number

Clinical Notes / Justification

Prior Treatment Attempted

Clinical Attachment(s) / Supporting Documentation

Upload

Size limit: 100 MB. File limit: 10.

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