pAMS STAFF ACCESS REQUEST form - BILLING & PRIOR AUTHORIZATION

Patient Name *

First Name

Last Name

Date of Birth: (ex: Month, Day, Year: January, 01, 1990)

MM

DD

YYYY

Common Requests:

General billing inquiries

Prior authorization requests for procedures or medications

Questions about coding for specific services

Help with what documentation is needed for insurance approval

Appeals for denied claims

Clarifying patient balances or payment plans

Something else