Rev. 10/27/2023
Authorization Request
Fax this form with all pertinent clinical
information
to Medical Management at:
918-878-5900 or 1-800-594-0105
(toll free fax number)
Patient Name:
ID Number:
Patient Phone Number:
Date of Birth (DOB):
Ordering Physician:
Phone Number: Fax Number:
Type of Service/
Service Category:
Office Visit Diagnostic Testing
Outpatient Procedure
DME
SNF
ER/Urgent Care
Inpatient
Observation
Inpatient Rehab
LTAC
Other:
Priority: Urgent Routine Retro
To be determined
Quantity:
Dates of Service(s):
Servicing Provider/Facility:
Diagnosis Code(s): Diagnosis(es):
CPT Code(s): Procedure(s):
Remarks/Additional Information:
Please fill out this form completely. Questions? Call Medical Management at 918-594-5228 or 800-594-0089
Authorization means that CommunityCare has determined the requested service are medically necessary and appropriate. This
authorization does not guarantee payment. The member must be eligible on the date the service is rendered for this authorization to be
valid. CommunityCare does not guarantee eligibility for patients covered by a group health
plan or any Medicare plan, but relies on eligibility
information provided to it by the employer or CMS. Payment is subject to benefit plan limits. The patient is financially responsible for the
cost of the authorized services received if he/she is determined ineligible for coverage or exceeds benefit plan limits.
Contact Name :
Date:
Phone Number:
Fax Number:
Williams Center Tower II | Two West Second Street, Suite 100 | Tulsa, Oklahoma 74103
918.594.5200 | Toll Free: 1.800.278.7563 | TTY/TDD: 1.800.722.0353
www.ccok.com
By checking this box, I certify that the phone number and fax
number listed above are accurate, secure, and confidential.
Clinical information (such as previous diagnostic testing, medications, etc.) should accompany this request to determine
medical necessity. Failure to submit pertinent, supporting documentation can result in the request being denied.
