AAH Prior Authorization Request

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Fax: (855) 891-7174

Telephone: (510) 747-4540

Note: All fields that are BOLDED are required.

Authorizations are based on medical necessity and covered services. Authorizations are contingent upon member’s eligibility and are not a guarantee of payment. The provider is responsible for verifying member’s eligibility on the date of service.
Member must be eligible on date of service and procedure must be a covered benefit. REMAINING BALANCE MAY
NOT BE BILLED TO THE PATIENT. If interested in becoming an AAH contracted provider, contact Provider Services at
(510) 747-4510. Please verify eligibility using one of the following methods:
1. Web: https://www.alamedaalliance.org
2. AAH Customer Service: (510) 747-4567
TYPE OF REQUEST (please check only one):

REQUESTING PROVIDER

Routine

Name:

Urgent

Address:

Approval based on AAH clinical review. AAH has up to 5 business days to process routine requests.
Inappropriate use will be monitored. AAH has up to
72 hours to process urgent requests for all lines of business.

City: HAYWARD

Only granted for member eligibility issues or for services rendered in emergent or urgent situation.

State: CA

Zip: 94545

Retro

NPI #:

Modification

Request for existing authorized services.
Please enter the AAH Auth Number and the Member information below. Use a separate sheet to specify your changes or to attach additional supporting documentation.

Office Contact:

Fx:

Email:
(For newborn services provide mother's information and check newborn fields below)

First Name:

JILL

Last Name:

ORBINE

Date of Birth:
Address:

Phone:

If Mod, AAH AUTH #:
MEMBER

1265737175

Health Plan ID#: 802473902
Newborn

05/18/1966

Phone:
Other Insurance (i.e. Commercial, Medicare A, B):

16857 CLINTON AVE

City: SAN LEANDRO

State: CA

Zip: 94578

PLACE OF SERVICE (Check one – please do not circle):
Inpatient Hospital

DOB:

Outpatient Hospital

Facility

Provider’s Office

Ambulatory Surgical Center

Home

RENDERING PROVIDER

Name/Facility: WE CARE REHAB SERVICE INC. Phone:

PHYSICAL THERAPY

Specialty/Dept:
NPI#:

Fax:

TIN#:

(510)264-4202

(510)264-4192

Address:

27200 CALAROGA AVE

City: HAYWARD

Anticipated Date of Service:

State: CA

Zip: 94545

Non-Contracted. Provide reason for out of network provider request. Please do not enter general comments here.

DIAGNOSES / SERVICE CODES
ICD-9
Code(s):

Please DO NOT describe the procedures; only enter the Code, Modifier, and Quantity.

724.5

CPT/HCPCS

Mod

Qty

CPT/HCPCS

Mod

Qty

CPT/HCPCS

Mod

Qty

CPT/HCPCS

Mod

Qty

12

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