Preauthorization Request Form
[Date]
[Insurer name]
Attn: [Name of individual]
[Address]
re: [Patient name]
[Policy number]
Diagnosis Code(s): ________________________________
Area(s) of the body requiring treatment:
| ___ Left Arm | ___ Right Arm | ___ Axillary (Underarms) | ___ Palmar (Hands) |
| ___ Right Leg | ___ Left Leg | ___ Plantar (Feet) | |
| ___ Craniofacial (Face/Head) | ___ Upper thorax | ___ Lower abdomen | ___ Groin |
| ___ Other (please specify):______________________________________________________________________________ | |||
Impairment of Daily Activities, & Impact on Quality of Life:
| ___ Emotional state | ___ Relationships with family & friends |
___ Work & professional life |
___ Developing personal relationships |
| ___ Shaking hands | ___ Education | ___ Sexual activities |
Previous Treatments:
| ___ UVA Phototherapy | ___UVB Phototherapy |
| ___ Topical Steroid
List: ______________________________________________ |
___ Oral Steroid
List: ______________________________________________ |
| ___ Surgery (MKTP)
List: _______________________________________________ |
___ None |
Recommended Treatment for:
| ___ Left Arm | ___ Right Arm | ___ Axillary (Underarms) | ___ Palmar (Hands) |
| ___ Right Leg | ___ Left Leg | ___ Plantar (Feet) | |
| ___ Craniofacial (Face/Head) | ___ Upper thorax | ___ Lower abdomen | ___ Groin |
| ___ Other (please specify):______________________________________________________________________________ | |||
Requesting Treatment(s)
| ___ UVA Phototherapy | ___UVB Phototherapy |
| ___ Topical Steroid
List: ______________________________________________ |
___ Oral Steroid
List: ______________________________________________ |
| ___ Surgery (MKTP)
List: _______________________________________________ |
___ Other
List: ______________________________________________ |
| Notes: |
Treating Physician: __________________________________________________________________
Signature: Date: __________________
ICD 10 Codes
Vitiligo L80
- Eyelid – H02.739
- Short description: Vitiligo of unsp eye, unspecified eyelid and periocular area
- Left Eyelid – H02.736
- Lower – H02.735
- Upper – H02.734
- Right Eyelid – H02.733
- Lower – H02.732
- Upper – H02.731
- Pinta A67.2
- Applicable To
- Achromic skin lesions of pinta
- Cicatricial skin lesions of pinta
- Dyschromic skin lesions of pinta
- Approximate Synonyms
- Cardiovascular lesions of pinta
- Dyschromic skin lesions of pinta
- Pinta, cardiovascular lesions
- Pinta, dyschromic skin lesions
- Pinta, late lesion
- Pinta, vitiligo
- Vitiligo of pinta
- Applicable To
- Vulva N90.89
- Short description: Other noninflammatory disorders of vulva and perineum
Text from this page is adapted from and used with permission from the International Hyperhidrosis Society www.SweatHelp.org.
