{"id":1687,"date":"2021-03-26T19:07:38","date_gmt":"2021-03-26T19:07:38","guid":{"rendered":"https:\/\/stage.projects-delivery.com\/wp\/primecare\/?page_id=1687"},"modified":"2021-04-28T02:04:45","modified_gmt":"2021-04-28T02:04:45","slug":"pa-request","status":"publish","type":"page","link":"https:\/\/stage.projects-delivery.com\/wp\/primecare\/pa-request\/","title":{"rendered":"pa.Request"},"content":{"rendered":"<p>[vc_row][vc_column][vc_empty_space][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text]<\/p>\n<h2 class=\"Main-seond-Heading\" style=\"text-align: center;\">Initial Request Form<\/h2>\n<p class=\"Paragraph-text\" style=\"text-align: center;\">Contact us @214-613-2019 or complete the form below to request management of a prior authorization\/precertification request, and a Prime Care Health Solutions team member will reach out to you to complete your request.<\/p>\n<p>[\/vc_column_text][\/vc_column][\/vc_row][vc_row css=&#8221;.vc_custom_1616786051441{padding-top: 35px !important;padding-right: 35px !important;padding-bottom: 35px !important;padding-left: 35px !important;background-color: #ffffff !important;background-position: center !important;background-repeat: no-repeat !important;background-size: cover !important;}&#8221;][vc_column][vc_column_text]<\/p>\n<h2 style=\"text-align: center; color: #69696e; font-size: 30px; font-weight: 400; line-height: 35px;\">Prior Authorization (PA) Management Initial Request Form<\/h2>\n<p>[\/vc_column_text][vc_column_text]<\/p>\n<p style=\"text-align: center;\"><style type=\"text\/css\">.super-form:not(.super-initialized) *:not(.super-load-icon) { visibility: hidden !important; }<\/style><div id=\"super-form-1671\" style=\"margin:0px 0px 0px 0px;\" class=\"super-form super-form-1671  super-default-squared super-field-size-large super-adaptive\" data-hide=\"true\" data-overlay=\"true\" data-field-size=\"large\"><span class=\"super-load-icon\"><\/span><form tabindex=\"0\" autocomplete=\"on\" enctype=\"multipart\/form-data\"><input type=\"hidden\" name=\"sf_nonce\" value=\"\" \/><input type=\"text\" name=\"super_hp\" size=\"25\" value=\"\" \/><div class=\"super-shortcode super-field super-hidden\"><input class=\"super-shortcode-field\" type=\"hidden\" value=\"1671\" name=\"hidden_form_id\" \/><\/div><div class=\"super-shortcode super-multipart super-active \" data-step-auto=\"no\" data-prev-text=\"Prev\" data-next-text=\"Next\" data-step-name=\"Step 1\" data-step-description=\"Description for this step\"><div class=\"super-shortcode super-field super-heading   super-ungrouped  \"><div class=\"super-heading-title\"><h1 style=\"font-size:25px;line-height:30px;\">Select preferred PA Management service*<\/h1><\/div><\/div><div class=\"super-shortcode super-field super-radio   super-ungrouped   display-vertical\"><div class=\"super-field-wrapper \"><div class=\"super-items-list\"><label class=\"super-item\" ><span class=\"super-before\"><span class=\"super-after\"><\/span><\/span><input type=\"radio\" value=\"One-time OR as needed management of prior authorization cases\" \/><div>One-time OR as needed management of prior authorization cases<\/div><\/label><label class=\"super-item\" ><span class=\"super-before\"><span class=\"super-after\"><\/span><\/span><input type=\"radio\" value=\"Monthly management of 1 to 49 prior authorization cases per month\" \/><div>Monthly management of 1 to 49 prior authorization cases per month<\/div><\/label><label class=\"super-item\" ><span class=\"super-before\"><span class=\"super-after\"><\/span><\/span><input type=\"radio\" value=\"Monthly management of 50 to 100 prior authorization cases per month\" \/><div>Monthly management of 50 to 100 prior authorization cases per month<\/div><\/label><label class=\"super-item\" ><span class=\"super-before\"><span class=\"super-after\"><\/span><\/span><input type=\"radio\" value=\"Monthly management of over 100 prior authorization cases per month\" \/><div>Monthly management of over 100 prior authorization cases per month<\/div><\/label><\/div><input class=\"super-shortcode-field\" type=\"hidden\" name=\"option\" value=\"\" data-oname=\"option\" data-validation=\"empty\" data-email=\"Option:\" data-absolute-default=\"\" data-default-value=\"\" \/><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-heading   super-ungrouped  \"><div class=\"super-heading-title\"><h1 style=\"font-size:25px;line-height:30px;\">Referring Physician or Provider Information<\/h1><\/div><div class=\"super-heading-description\" ><div>Provide information about the provider requesting the referral.<\/div><\/div><\/div><div class=\"super-grid super-shortcode\"><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-1 first-column \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"first_name\" data-oname=\"first_name\" data-validation=\"empty\" data-email=\"Last Name :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your Last Name\" data-placeholderFilled=\"Your Last Name \"><span>Your Last Name<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-2  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"field_UaRdI\" data-oname=\"field_UaRdI\" data-validation=\"empty\" data-email=\"First Name:\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your First Name\" data-placeholderFilled=\"First Name\"><span>Your First Name<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-3  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"field_lUvCM\" data-oname=\"field_lUvCM\" data-validation=\"empty\" data-email=\"Middle Name :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your Middle Name\" data-placeholderFilled=\"Your Middle Name\"><span>Your Middle Name<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><\/div><div class=\"super-grid super-shortcode\"><div class=\"super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"NPI_Number\" data-oname=\"NPI_Number\" data-validation=\"empty\" data-email=\"NPI Number\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"NPI Number\" data-placeholderFilled=\"NPI Number\"><span>NPI Number<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_half super-column grid-level-0 column-number-2  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"_Specialty\" data-oname=\"_Specialty\" data-validation=\"empty\" data-email=\"Specialty\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\" Specialty\" data-placeholderFilled=\" Specialty\"><span> Specialty<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><\/div><\/div><div class=\"super-shortcode super-multipart\" data-step-auto=\"no\" data-prev-text=\"Prev\" data-next-text=\"Next\" data-step-name=\"Step 1\" data-step-description=\"Description for this step\"><div class=\"super-shortcode super-field super-heading   super-ungrouped  \"><div class=\"super-heading-title\"><h1 style=\"font-size:25px;line-height:30px;\">Practice Contact Information<\/h1><\/div><div class=\"super-heading-description\" ><div>Provide information about the contact person for referral<\/div><\/div><\/div><div class=\"super-grid super-shortcode\"><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-1 first-column \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Last_Name\" data-oname=\"Last_Name\" data-validation=\"empty\" data-email=\"Your First Name\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your First Name \" data-placeholderFilled=\"Your First Name \"><span>Your First Name <\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-2  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"field_zgtRi\" data-oname=\"field_zgtRi\" data-validation=\"empty\" data-email=\"Last Name*\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your Last Name*\" data-placeholderFilled=\"Last Name*\"><span>Your Last Name*<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-3  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"_Title\" data-oname=\"_Title\" data-validation=\"empty\" data-email=\"Title\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\" Title\" data-placeholderFilled=\" Title\"><span> Title<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><\/div><div class=\"super-grid super-shortcode\"><div class=\"super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Clinic_Facility_Name\" data-oname=\"Clinic_Facility_Name\" data-validation=\"empty\" data-email=\"Clinic \/ Facility Name*\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your Clinic \/ Facility Name*\" data-placeholderFilled=\"Clinic \/ Facility Name*\"><span>Your Clinic \/ Facility Name*<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"City\" data-oname=\"City\" data-validation=\"empty\" data-email=\"City*\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your City*\" data-placeholderFilled=\"City*\"><span>Your City*<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_half super-column grid-level-0 column-number-2  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"_Clinic_Facility_Address\" data-oname=\"_Clinic_Facility_Address\" data-validation=\"empty\" data-email=\"Clinic \/ Facility Address*\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your Clinic \/ Facility Address*\" data-placeholderFilled=\" Clinic \/ Facility Address*\"><span>Your Clinic \/ Facility Address*<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"_State\" data-oname=\"_State\" data-validation=\"empty\" data-email=\"State*\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\" State*\" data-placeholderFilled=\" State*\"><span> State*<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><\/div><div class=\"super-grid super-shortcode\"><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-1 first-column \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"tel\" name=\"Phone_number\" data-oname=\"Phone_number\" data-validation=\"phone\" data-email=\"Phone number\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your Phone number\" data-placeholderFilled=\"Phone number\"><span>Your Phone number<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-2  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Fax\" data-oname=\"Fax\" data-email=\"Fax :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\" Fax\" data-placeholderFilled=\" Fax\"><span> Fax<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-3  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"email\" name=\"email\" data-oname=\"email\" data-validation=\"email\" data-email=\"E-mail address:\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your E-mail Address\" data-placeholderFilled=\"E-mail Address\"><span>Your E-mail Address<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><\/div><\/div><div class=\"super-shortcode super-multipart\" data-step-auto=\"no\" data-prev-text=\"Prev\" data-next-text=\"Next\" data-step-name=\"Step 1\" data-step-description=\"Description for this step\"><div class=\"super-shortcode super-field super-heading   super-ungrouped  \"><div class=\"super-heading-title\"><h1 style=\"font-size:25px;line-height:30px;\">Patient Information<\/h1><\/div><\/div><div class=\"super-grid super-shortcode\"><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-1 first-column \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"first_name_patient\" data-oname=\"first_name_patient\" data-validation=\"empty\" data-email=\"First Name:\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your First Name\" data-placeholderFilled=\"First Name\"><span>Your First Name<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-2  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"field_muyma\" data-oname=\"field_muyma\" data-validation=\"empty\" data-email=\"Last name :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Last name\" data-placeholderFilled=\"Last name\"><span>Last name<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-3  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"_Middle_name\" data-oname=\"_Middle_name\" data-validation=\"empty\" data-email=\"Middle name :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your  Middle name\" data-placeholderFilled=\" Middle name\"><span>Your  Middle name<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><\/div><div class=\"super-grid super-shortcode\"><div class=\"super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column \"><div class=\"super-shortcode super-field super-date   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field super-datepicker\" type=\"text\" autocomplete=\"false\"  value=\"\" \r\n        name=\"Date_of_Birth\" \r\n        data-format=\"dd-mm-yy\" \r\n        data-jsformat=\"dd-MM-yyyy\" \r\n        data-connected-min=\"\" \r\n        data-connected-min-days=\"1\" \r\n        data-connected-max=\"\" \r\n        data-connected-max-days=\"1\" \r\n        data-range=\"-100:+0\" \r\n        data-first-day=\"1\"\r\n        data-localization=\"\"\r\n        data-change-month=\"true\"\r\n        data-change-year=\"true\"\r\n        data-show-month-after-year=\"\"\r\n        data-show-week=\"\"\r\n        data-number-of-months=\"1\"\r\n        data-show-other-months=\"\"\r\n        data-select-other-months=\"false\" data-work-days=\"true\"data-weekends=\"true\"data-maxPicks=\"1\" data-oname=\"Date_of_Birth\" data-validation=\"empty\" data-email=\"Date of Birth :\" data-absolute-default=\"\" data-default-value=\"\" data-return_age=\"\" readonly=\"true\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Date of Birth\" data-placeholderFilled=\"Date of Birth\"><span>Date of Birth<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_half super-column grid-level-0 column-number-2  \"><div class=\"super-shortcode super-field super-radio super-has-only-label   super-ungrouped   display-vertical\"><div class=\"super-label super-bottom-margin\">Gender<\/div><div class=\"super-field-wrapper \"><div class=\"super-items-list\"><label class=\"super-item\" ><span class=\"super-before\"><span class=\"super-after\"><\/span><\/span><input type=\"radio\" value=\"Male\" \/><div>Male<\/div><\/label><label class=\"super-item\" ><span class=\"super-before\"><span class=\"super-after\"><\/span><\/span><input type=\"radio\" value=\"Female\" \/><div>Female<\/div><\/label><\/div><input class=\"super-shortcode-field\" type=\"hidden\" name=\"Gender\" value=\"\" data-oname=\"Gender\" data-validation=\"empty\" data-email=\"Gender :\" data-absolute-default=\"\" data-default-value=\"\" \/><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"address\" data-oname=\"address\" data-validation=\"empty\" data-email=\"Address:\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your Address\" data-placeholderFilled=\"Address\"><span>Your Address<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-grid super-shortcode\"><div class=\"super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"city\" data-oname=\"city\" data-validation=\"empty\" data-email=\"City:\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"City\" data-placeholderFilled=\"City\"><span>City<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_half super-column grid-level-0 column-number-2  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"State\" data-oname=\"State\" data-validation=\"empty\" data-email=\"State :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"State\" data-placeholderFilled=\"State\"><span>State<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><\/div><div class=\"super-grid super-shortcode\"><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-1 first-column \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"tel\" name=\"Preferred_Phone_number\" data-oname=\"Preferred_Phone_number\" data-validation=\"phone\" data-email=\"Preferred Phone number :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Preferred Phone number \" data-placeholderFilled=\"Preferred Phone number \"><span>Preferred Phone number <\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-2  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"tel\" name=\"Alternate_Phone_number\" data-oname=\"Alternate_Phone_number\" data-validation=\"phone\" data-email=\"Alternate Phone number :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Alternate Phone number\" data-placeholderFilled=\"Alternate Phone number\"><span>Alternate Phone number<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-3  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"email\" name=\"email_1\" data-oname=\"email_1\" data-validation=\"email\" data-email=\"E-mail address:\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Your E-mail Address\" data-placeholderFilled=\"E-mail Address\"><span>Your E-mail Address<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><\/div><div class=\"super-grid super-shortcode\"><div class=\"super-shortcode super_one_half super-column grid-level-0 column-number-1 first-column \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Patient_Insurance_State\" data-oname=\"Patient_Insurance_State\" data-email=\"Patient Insurance State :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Patient Insurance State\" data-placeholderFilled=\"Patient Insurance State\"><span>Patient Insurance State<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Pharmacy_insurance_member_ID_number\" data-oname=\"Pharmacy_insurance_member_ID_number\" data-email=\"Pharmacy insurance member ID number :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Pharmacy insurance member ID number\" data-placeholderFilled=\"Pharmacy insurance member ID number\"><span>Pharmacy insurance member ID number<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Pharmacy_BIN_numberq\" data-oname=\"Pharmacy_BIN_numberq\" data-email=\"Pharmacy BIN number :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Pharmacy BIN number\" data-placeholderFilled=\"Pharmacy BIN number\"><span>Pharmacy BIN number<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_half super-column grid-level-0 column-number-2  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Pharmacy_insurance_plan_or_PBM_name\" data-oname=\"Pharmacy_insurance_plan_or_PBM_name\" data-email=\"Pharmacy insurance plan or PBM name :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Pharmacy insurance plan or PBM name\" data-placeholderFilled=\"Pharmacy insurance plan or PBM name\"><span>Pharmacy insurance plan or PBM name<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Pharmacy_insurance_group_number\" data-oname=\"Pharmacy_insurance_group_number\" data-email=\"Pharmacy insurance group number :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Pharmacy insurance group number\" data-placeholderFilled=\"Pharmacy insurance group number\"><span>Pharmacy insurance group number<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"_Pharmacy_PCN_number\" data-oname=\"_Pharmacy_PCN_number\" data-email=\"Pharmacy PCN number :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\" Pharmacy PCN number\" data-placeholderFilled=\" Pharmacy PCN number\"><span> Pharmacy PCN number<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><\/div><div class=\"super-grid super-shortcode\"><div class=\"super-shortcode super_one_full super-column grid-level-0 column-number-1 first-column \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Diagnosis\" data-oname=\"Diagnosis\" data-email=\"Diagnosis :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Diagnosis\" data-placeholderFilled=\"Diagnosis\"><span>Diagnosis<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Medical_insurance_name_primary_carriers_name_Insured_member_ID_number_group_number_coverage_date_effective_date_and_customer_service_number\" data-oname=\"Medical_insurance_name_primary_carriers_name_Insured_member_ID_number_group_number_coverage_date_effective_date_and_customer_service_number\" data-email=\"Medical insurance name, primary carriers name (Insured), member ID number, group number, coverage date, effective date and customer service number :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Medical insurance name, primary carriers name (Insured), member ID number, group number, coverage date, effective date and customer service number\" data-placeholderFilled=\"Medical insurance name, primary carriers name (Insured), member ID number, group number, coverage date, effective date and customer service number\"><span>Medical insurance name, primary carriers name (Insured), member ID number, group number, coverage date, effective date and customer service number<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Pharmacy_insurance_name_primary_carriers_name_Insured_member_ID_number_BIN_number_group_number_coverage_date_effective_date_and_customer_service_number\" data-oname=\"Pharmacy_insurance_name_primary_carriers_name_Insured_member_ID_number_BIN_number_group_number_coverage_date_effective_date_and_customer_service_number\" data-email=\"Pharmacy insurance name, primary carriers name (Insured), member ID number, BIN number, group number, coverage date, effective date and customer service number :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Pharmacy insurance name, primary carriers name (Insured), member ID number, BIN number, group number, coverage date, effective date and customer service number\" data-placeholderFilled=\"Pharmacy insurance name, primary carriers name (Insured), member ID number, BIN number, group number, coverage date, effective date and customer service number\"><span>Pharmacy insurance name, primary carriers name (Insured), member ID number, BIN number, group number, coverage date, effective date and customer service number<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><\/div><\/div><div class=\"super-shortcode super-multipart\" data-step-auto=\"no\" data-prev-text=\"Prev\" data-next-text=\"Next\" data-step-name=\"Step 1\" data-step-description=\"Description for this step\"><div class=\"super-shortcode super-field super-heading   super-ungrouped  \"><div class=\"super-heading-title\"><h1 style=\"font-size:25px;line-height:30px;\">Drug Information & Diagnosis<\/h1><\/div><div class=\"super-heading-description\" ><div>Provide information about the medication prescribed and diagnosis<\/div><\/div><\/div><div class=\"super-grid super-shortcode\"><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-1 first-column \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Medication_name\" data-oname=\"Medication_name\" data-validation=\"empty\" data-email=\"Medication name :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Medication name* \" data-placeholderFilled=\"Medication name*\"><span>Medication name* <\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Dose\" data-oname=\"Dose\" data-validation=\"empty\" data-email=\"Dose :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Dose\" data-placeholderFilled=\"Dose\"><span>Dose<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"ICD-10_Diagnosis\" data-oname=\"ICD-10_Diagnosis\" data-validation=\"empty\" data-email=\"ICD-10 Diagnosis :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"ICD-10 Diagnosis\" data-placeholderFilled=\"ICD-10 Diagnosis\"><span>ICD-10 Diagnosis<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-2  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"_Strength\" data-oname=\"_Strength\" data-validation=\"empty\" data-email=\"Strength :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\" Strength \" data-placeholderFilled=\" Strength :\"><span> Strength <\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"Quantity\" data-oname=\"Quantity\" data-validation=\"empty\" data-email=\"Quantity :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"Quantity\" data-placeholderFilled=\"Quantity\"><span>Quantity<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"or_ICD-9_Diagnosis\" data-oname=\"or_ICD-9_Diagnosis\" data-validation=\"empty\" data-email=\"or ICD-9 Diagnosis :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\"or ICD-9 Diagnosis\" data-placeholderFilled=\"or ICD-9 Diagnosis\"><span>or ICD-9 Diagnosis<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><div class=\"super-shortcode super_one_third super-column grid-level-0 column-number-3  \"><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"_Formulation\" data-oname=\"_Formulation\" data-validation=\"empty\" data-email=\"Formulation :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\" Formulation\" data-placeholderFilled=\" Formulation :\"><span> Formulation<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><div class=\"super-shortcode super-field super-text   super-ungrouped  \"><div class=\"super-field-wrapper \"><input tabindex=\"-1\" class=\"super-shortcode-field\" type=\"text\" name=\"_Direction_SIG_interval\" data-oname=\"_Direction_SIG_interval\" data-validation=\"empty\" data-email=\"Direction (SIG) interval :\" data-absolute-default=\"\" data-default-value=\"\" \/><span class=\"super-adaptive-placeholder\" data-placeholder=\" Direction (SIG) interval*\" data-placeholderFilled=\" Direction (SIG) interval*\"><span> Direction (SIG) interval*<\/span><\/span><\/div><div class=\"super-error-msg\">Field is required!<\/div><div class=\"super-empty-error-msg\">Field is required!<\/div><\/div><\/div><\/div><\/div><div data-color=\"#f26c68\" data-light=\"#ff807c\" data-dark=\"#d44e4a\" data-hover-color=\"#444444\" data-hover-light=\"#585858\" data-hover-dark=\"#262626\" data-font=\"#ffffff\" data-font-hover=\"#ffffff\" data-radius=\"square\" data-type=\"flat\" class=\"super-extra-shortcode super-shortcode super-field super-button super-clear-none super-form-button super-radius-square super-type-flat super-button-medium super-button-align-left super-button-width-auto\"><div data-href=\"\" class=\"super-button-wrap no_link\"><div class=\"super-button-name\" data-action=\"submit\" data-normal=\"Submit\" data-loading=\"Loading...\">Submit<\/div><span class=\"super-after\"><\/span><\/div><\/div><\/form><\/div>\n<p>[\/vc_column_text][\/vc_column][\/vc_row][vc_row][vc_column][vc_empty_space][\/vc_column][\/vc_row][vc_row full_width=&#8221;stretch_row&#8221; css=&#8221;.vc_custom_1616786426846{margin-bottom: -30px !important;padding-top: 45px !important;padding-bottom: 45px !important;background-color: #17660e !important;background-position: center !important;background-repeat: no-repeat !important;background-size: cover !important;}&#8221;][vc_column][vc_column_text]<\/p>\n<p class=\"copy-right-text-footer\" style=\"text-align: center;\">Copyright \u00a9 2021 Prior Authorization\/Pre-Certification Management Services,<br \/>\nPrime Care Health Solutions<\/p>\n<p>[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>[vc_row][vc_column][vc_empty_space][\/vc_column][\/vc_row][vc_row][vc_column][vc_column_text] Initial Request Form Contact us @214-613-2019 or complete the form below to request management of a prior authorization\/precertification request, and a Prime Care Health Solutions<span class=\"excerpt-hellip\"> [\u2026]<\/span><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1687","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/stage.projects-delivery.com\/wp\/primecare\/wp-json\/wp\/v2\/pages\/1687","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stage.projects-delivery.com\/wp\/primecare\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/stage.projects-delivery.com\/wp\/primecare\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/stage.projects-delivery.com\/wp\/primecare\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/stage.projects-delivery.com\/wp\/primecare\/wp-json\/wp\/v2\/comments?post=1687"}],"version-history":[{"count":14,"href":"https:\/\/stage.projects-delivery.com\/wp\/primecare\/wp-json\/wp\/v2\/pages\/1687\/revisions"}],"predecessor-version":[{"id":2082,"href":"https:\/\/stage.projects-delivery.com\/wp\/primecare\/wp-json\/wp\/v2\/pages\/1687\/revisions\/2082"}],"wp:attachment":[{"href":"https:\/\/stage.projects-delivery.com\/wp\/primecare\/wp-json\/wp\/v2\/media?parent=1687"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}