Trilogy Referral Form - Independent Physicians Network

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TRILOGY AUTHORIZATION FORM

Expedited/Urgent

Yes

Patient Name

Patient ID#

Patient DOB

Referred by

Phone

Fax

Referred To

Requested Dates From

Requested Dates To

Units/Visits

Diagnosis (ICD-9)

Procedure (CPT/HCPCS)

Your Email Address

The following authorizations require the additional documentation listed to be faxed along with this form to IPN at (414) 771-1159:

• Diagnostic Procedure – Physician Order
• Durable Medical Equipment (Purchase or Rental) – Physicians Order & State Prior Auth/Oxygen Attachment
• Durable Medical Equipment (Repair) – Physicians Order and Work Order
• Home Health – 485 Form
• Hospice – State Physician Certification & Recertification of Terminal Illness
• PCW – PA/RF & HCAF & 485 & PCW Instructions
• Rehabilitation – Physician Order & Initial Evaluation
• RN Supervisory – PA/RF & HCAF & 485 & PCW Instructions
• Therapy (PT/OT/SP)requires Physician Order & Initial Evaluation

Clinical notes/Additional Information