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

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

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

Requesting Facility Information (Please fill out the form completely)

Injured Party (PATIENT)

Attorney Information

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

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

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