Prior Authorization (PA) Request Form – Adult Palliative Care (Alameda Alliance for Health) Completed Form Examples and Samples
View a detailed example of a completed Prior Authorization (PA) Request Form for Adult Palliative Care for Alameda Alliance for Health. This sample demonstrates how to correctly fill out the form, including patient details, provider information, ICD-10 and CPT codes, and a strong clinical justification. Use our guide to help ensure your PA request is accurate and complete.
Prior Authorization (PA) Request Form – Adult Palliative Care (Alameda Alliance for Health) Example
How this form was filled:
This example shows a completed Prior Authorization request for an adult patient with Stage IV COPD. It includes all necessary patient, requesting provider, and servicing provider information, along with the specific diagnosis (ICD-10) and requested services (CPT codes) with a detailed clinical justification for palliative care consultation.
Information used to fill out the document:
- Patient Name: Maria Garcia
- Patient DOB: 05/20/1956
- Patient ID: AAH123456789
- Patient Address: 123 Lake Merritt Blvd, Oakland, CA 94612
- Requesting Provider: Dr. Emily Chen, MD
- Requesting Provider NPI: 1234567890
- Requesting Facility: Oakland Community Health Clinic
- Servicing Provider: Dr. Robert Davis, MD (Bay Area Palliative Care Group)
- Servicing Provider NPI: 0987654321
- Primary Diagnosis: J44.9 - Chronic obstructive pulmonary disease, unspecified
- Secondary Diagnosis: F41.9 - Anxiety disorder, unspecified; R53.83 - Other fatigue
- Requested Service (CPT): 99245 - Office or other outpatient consultation
- Requested Units/Visits: 1 consultation, then 4 follow-up visits
- Date of Request: 04/08/2026
- Anticipated Dates of Service: 04/15/2026 - 08/15/2026
- Clinical Justification: Patient is a 70 y/o female with Stage IV COPD experiencing progressive dyspnea, significant fatigue, and anxiety, which are severely impacting her quality of life and ability to perform ADLs. Palliative care consultation is medically necessary to provide specialized symptom management, establish goals of care, and facilitate advance care planning. The goal is to improve comfort and support the patient and family.
What this filled form sample shows:
- Clearly identified patient and provider information, including names and NPI numbers.
- A specific ICD-10 diagnosis code (J44.9) that qualifies the patient for palliative care.
- Precise CPT codes for the requested consultation and follow-up services.
- A comprehensive clinical justification detailing the medical necessity and goals of the palliative care intervention.
Form specifications and details:
| Form Name: | Prior Authorization (PA) Request Form – Adult Palliative Care |
| Health Plan: | Alameda Alliance for Health |
| Use Case: | Initial request for palliative care services for a patient with a qualifying chronic illness (Stage IV COPD). |
Created: February 05, 2026 09:45 PM
