Alameda Alliance for Health Prior Authorization (PA) Request Form – Adult Palliative Care Completed Form Examples and Samples
Explore a filled-out example of the Alameda Alliance for Health Prior Authorization (PA) Request Form for Adult Palliative Care. This sample provides a clear guide for healthcare providers on how to complete the form accurately, including patient details, provider information, ICD-10 codes, and clinical justification to streamline the approval process.
Alameda Alliance Adult Palliative Care PA Form Example
How this form was filled:
This is a sample of a completed Alameda Alliance for Health Prior Authorization (PA) Request Form for an adult patient with advanced Chronic Obstructive Pulmonary Disease (COPD) requiring palliative care. It includes correctly filled patient demographics, provider information, relevant ICD-10 diagnosis codes, and a clear request for palliative care consultation and ongoing services.
Information used to fill out the document:
- Patient Name: Jane A. Smith
- Patient DOB: 10/15/1958
- Alameda Alliance ID: A123456789
- Patient Address: 456 Oak Avenue, Oakland, CA 94612
- Requesting Provider: Robert Green, MD
- Requesting Provider NPI: 1122334455
- Requesting Provider Group: East Bay Pulmonology Group
- Rendering Provider/Group: Hopeful Horizons Palliative Care
- Rendering Provider NPI: 9988776655
- Primary Diagnosis: J44.9 - Chronic obstructive pulmonary disease, unspecified
- Secondary Diagnosis: R06.02 - Shortness of breath (Dyspnea)
- Tertiary Diagnosis: G89.4 - Chronic pain syndrome
- Date of Request: 06/01/2026
- Requested Service Start Date: 06/08/2026
- Requested Services: Initial Palliative Care Consultation, ongoing palliative care management including nursing visits, social work support, and symptom management.
- CPT Codes (if applicable): 99245 (Initial Consultation), 99378 (Medical team conference)
- Clinical Justification Summary: Patient is a 67-year-old female with progressive, advanced COPD, experiencing severe dyspnea and chronic pain significantly impacting her quality of life. Palliative care is requested for comprehensive symptom management, goals of care discussions, and psychosocial support for patient and family.
What this filled form sample shows:
- Accurate completion of patient and provider identification fields, including NPI numbers.
- Clear specification of the primary diagnosis and relevant secondary diagnoses using current ICD-10 codes.
- Detailed description of the requested palliative care services to establish medical necessity.
- Inclusion of a concise clinical justification summary to support the prior authorization request.
Form specifications and details:
| Form Name: | Alameda Alliance for Health Prior Authorization (PA) Request Form – Adult Palliative Care |
| Use Case: | Initial authorization for an adult patient with advanced COPD requiring comprehensive palliative care services. |
| Health Plan: | Alameda Alliance for Health |
| Submission Type: | Standard Prior Authorization Request |
Created: February 10, 2026 11:34 PM
