Patient Intake Submission

Pre-Authorization Form

First name

Middle Name

Last name

Gender

Male

Female

Birthday

Month

Day

Year

Address

Company name (if applicable)

Phone

Emergency Contact Name

Emergency Contact Phone

Relationship To Patient

Insurance/Coverage Card/File

Insurance Company Name

Member/Policy Number

Group Number

Claim Number (if applicable)

Adjuster / Case Manager Name

Adjuster Phone / Fax

Billing Address (if different)

Referring Physician or Facility

NPI (if applicable)

Referring Physician or Facility Address

Office Phone / Fax

Reason for Transport (Diagnosis / ICD-10 Code)

Medical Necessity Explanation

Attachment (if applicable)

Doctor’s order or prescription for transport

Medical records / discharge papers

Proof of insurance

Appointment confirmation letter

Police report (for PIP/auto claim)

Employer verification (for Workers’ Comp)

Attachment

Date(s) Service Requested

Type of Trip

One Way

Round Trip

Recurring

Pickup Address

Drop-off Address

Appointment Facility Name

Date and time of appointment

Month

Day

Year

Time

HoursMinutes

If Recurring input initial appointment

Return Time (if applicable)

Special Needs (if applicable)

Oxygen

Escort/Attendant

Other

Is Patient Contagious

Yes

Any Behavioral Concerns or Precautions

I authorize Raising Stars LLC to release and obtain medical and transportation information as needed to verify eligibility, obtain pre-authorization, and bill my insurance carrier(s), including PIP, Medicaid, Medicare, or Workers’ Compensation. I authorize payment of benefits directly to Raising Stars LLC for transportation services rendered.

I understand that:

Signature on file is valid for authorization and insurance billing purposes only.
I am financially responsible for any services not covered, denied, or partially paid by my insurance.
If services are denied or not covered, I may choose to continue transportation as a self-pay option through RaisingStarsLLC.com.
My information will be used and protected in accordance with HIPAA Privacy Regulations. A copy of the Privacy Notice is available upon request.

By signing below, I acknowledge and consent to these terms.

Signature

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Signature Required

Signature on file - Valid for authorization and insurance billing purposes only.