Procedure Authorization Request

Please complete the following form to request authorization of follow-up visits and/or procedures to be funded on a Red Rock lien or LOP. Multiple treatment types can be selected in one submission, such as 1. Surgery Center (facility charges), 2. Anesthesia, 3. Ortho/Spine.

Step 1: Fill out the form below to include cost estimate.
Step 2: Attach the clinical notes and Red Rock intake form from initial patient visit, if applicable.
Step 3: Submit

Medical Care Needed

Is this your first request for this patient?

YesNo

Please attach Red Rock Intake Form:

Please attach clinical/progress note from initial consult.

Is this request for Services Provided:

In Your OfficeOutside Referral - to another provider

Please attach signed physician script.

Treatment Requested

Date of Initial Visit

Next Appt. Date

CPT Coding for Procedure

Please list each CPT code, separated by comma (Ex: 92014, 72141)

Procedure Cost

Please list cost for each CPT code, separated by comma (Ex: $289.00, $1,521.00)

Description of Procedure/Treatment

Additional # of Visits Requested

Total Procedure/Treatment Cost

Total # of Visits Completed

Upload Rx Here

Additional Notes

Requesting Facility Information (Please fill out the form completely)

Your Facility Name

Your Name

Phone

Fax

State

Injured Party (PATIENT)

First Name

Last Name

Date of Accident

Date of Birth

Phone

Cell Phone

Address

City

State

Zip Code

Attorney Information

Firm Name

Contact at Firm

Phone

Fax

State

If you have trouble with this form or need to contact us directly:

preauth@redrockdiagnostics.com

Phone: (833) 277-7625 / Fax: (702) 202-2052

Red Rock Diagnostics, LLC ∙ P.O. Box 26119 Las Vegas, NV 89126

Contact Information