This form contains 166 fields organized into 10 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Authorization Change Request - Alliance Authorization Number
Alliance Authorization Number (Authorization Change Request)	Text	Enter the Alliance authorization number for the existing authorization you are requesting to change. Fill only if 'Authorization Change Request' is selected as 'Authorization Change Request'. Depends on: Authorization Change Request
Clinicals Attached Certification Checkbox
Certify clinicals attached	Checkbox	Check this box to certify that the required clinical documentation has been attached and will be submitted with this PA request form.
General
General Eligibility_1	CheckBox
General Eligibility_2	CheckBox
Member's Qualifying Condition_CHF	CheckBox
Member's Qualifying Condition_COPD	CheckBox
Member's Qualifying Condition_Advanced#20Cancer	CheckBox
Member's Qualifying Condition_Liver#20Disease	CheckBox
Member's Qualifying Condition_Advanced#20Dementia#2FAlzheimer's#20Dementia	CheckBox
Last Name	Text
Rendering/Servicing Provider First Name	Text
Rendering/Servicing Provider Specialty	Text
Rendering/Servicing Provider Address	Text
Rendering/Servicing Provider City	Text
Rendering/Servicing Provider State	Text
Rendering/Servicing Provider Zip Code	Text
Rendering/Servicing Provider NPI Number	Text
Rendering/Servicing Provider Tax ID Number	Text
Rendering/Servicing Provider Phone Number	Text
Rendering/Servicing Provider Fax Number	Text
Starting Service Date	Text
Ending Service Date (if known)	Text
Place of Service_Office#20#2811#29	CheckBox
Place of Service_Home#20#2812#29	CheckBox
Place of Service_Assisted#20Living#20#2813#29	CheckBox
Place of Service_Group#20Home#20#2814#29	CheckBox
Place of Service_Inpatient#20Hospital#20#2821#29	CheckBox
Place of Service_Outpatient#20Hospital#20#2822#29	CheckBox
Place of Service_Nursing#20Facility#20#2832#29	CheckBox
Place of Service_Custodial#20Care#20Facility#20#2833#29	CheckBox
Place of Service_ICF#2FDD#20#2854#29	CheckBox
Place of Service_Other#20#2899#29	CheckBox
Other (99) (specify)	Text
Is the service being requested out-of-network_Yes	RadioButton
Is the service being requested out-of-network_No	RadioButton
If Yes, provide the reacon for out-of-network facility provider_In-network#20provider#20not#20accepting#20new#20patients	CheckBox
If Yes, provide the reacon for out-of-network facility provider_In-network#20provider#20not#20available	CheckBox
If Yes, provide the reacon for out-of-network facility provider_Patient#20request	CheckBox
If Yes, provide the reacon for out-of-network facility provider_Specialized#20procedure#2FArea#20of#20expertise	CheckBox
If Yes, provide the reacon for out-of-network facility provider_Timely#20access#20to#20provider	CheckBox
If Yes, provide the reacon for out-of-network facility provider_Other	CheckBox
Other (specify)	Text
Is the service needed for discharge planning_Yes_2	RadioButton
Is the service needed for discharge planning_No_2	RadioButton
If Yes, what is the discharge date (MM/DD/YYYY)	Text
ICD Code(s)_Row_1	Text
ICD Code(s)_Row_1	Text
ICD Code(s)_Row_2	Text
ICD Code(s)_Row_2	Text
ICD Code(s)_Row_3	Text
ICD Code(s)_Row_3	Text
ICD Code(s)_Row_4	Text
ICD Code(s)_Row_4	Text
Code CPT/HCPCS_Row_1	Text
Description_Row_1	Text
Modifier 1_Row_1	Text
Modifier 2_Row_1	Text
Quantity_Row_1	Text
Unit Type_Row_1	Text
Total Billable Units_Row_1	Text
Code CPT/HCPCS_Row_2	Text
Description_Row_2	Text
Modifier 1_Row_2	Text
Modifier 2_Row_2	Text
Quantity_Row_2	Text
Unit Type_Row_2	Text
Total Billable Units_Row_2	Text
Code CPT/HCPCS_Row_3	Text
Description_Row_3	Text
Modifier 1_Row_3	Text
Modifier 2_Row_3	Text
Quantity_Row_3	Text
Unit Type_Row_3	Text
Total Billable Units_Row_3	Text
Code CPT/HCPCS_Row_4	Text
Description_Row_4	Text
Modifier 1_Row_4	Text
Modifier 2_Row_4	Text
Quantity_Row_4	Text
Unit Type_Row_4	Text
Total Billable Units_Row_4	Text
Code CPT/HCPCS_Row_5	Text
Description_Row_5	Text
Modifier 1_Row_5	Text
Modifier 2_Row_5	Text
Quantity_Row_5	Text
Unit Type_Row_5	Text
Total Billable Units_Row_5	Text
Code CPT/HCPCS_Row_6	Text
Description_Row_6	Text
Modifier 1_Row_6	Text
Modifier 2_Row_6	Text
Quantity_Row_6	Text
Unit Type_Row_6	Text
Total Billable Units_Row_6	Text
Code CPT/HCPCS_Row_7	Text
Description_Row_7	Text
Modifier 1_Row_7	Text
Modifier 2_Row_7	Text
Quantity_Row_7	Text
Unit Type_Row_7	Text
Total Billable Units_Row_7	Text
Code CPT/HCPCS_Row_8	Text
Description_Row_8	Text
Modifier 1_Row_8	Text
Modifier 2_Row_8	Text
Quantity_Row_8	Text
Unit Type_Row_8	Text
Total Billable Units_Row_8	Text
Code CPT/HCPCS_Row_9	Text
Description_Row_9	Text
Modifier 1_Row_9	Text
Modifier 2_Row_9	Text
Quantity_Row_9	Text
Unit Type_Row_9	Text
Total Billable Units_Row_9	Text
Code CPT/HCPCS_Row_10	Text
Description_Row_10	Text
Modifier 1_Row_10	Text
Modifier 2_Row_10	Text
Quantity_Row_10	Text
Unit Type_Row_10	Text
Total Billable Units_Row_10	Text
Primary_Row_1_Radiology	CheckBox
Primary_Row_2_Specialty#20Referral	CheckBox
Primary_Row_3_Stanford#20Oncology	CheckBox
Primary_Row_4_Tertiary#2F#20Quaternary#20Care#20#28T#2FQ#29	CheckBox
Primary_Row_1_2	CheckBox
Primary_Row_2_2	CheckBox
Primary_Row_3_2	CheckBox
Primary_Row_4_2	CheckBox
Member Information
Last Name	Text	Enter the member's last name.
First Name	Text	Enter the member's first name.
Date of Birth	Date	Enter the member's date of birth.
Alliance Member ID Number	Text	Enter the member's Alliance Member ID number.
Client Index Number (CIN)	Text	Enter the member's Client Index Number (CIN).
Medicare Beneficiary Identifier (MBI)	Text	Enter the member's Medicare Beneficiary Identifier (MBI).
Address	Text	Enter the member's street address.
City	Text	Enter the city for the member's address.
State	Text	Enter the state for the member's address.
Zip Code	Text	Enter the ZIP code for the member's address.
Phone Number	Text	Enter the member's phone number.
Other Insurance - Commercial
Commercial Insurance Name	Text	Enter the name of the member’s commercial insurance plan or insurance company. Fill only if 'Commercial' is 'Yes'. Depends on: Commercial
Commercial	Checkbox	Check this box if the member has other commercial insurance coverage (and include the insurance company name on the line provided).
Other Insurance - Medi-Cal
Medi-Cal	Checkbox	Check this box if the member has Medi-Cal as other insurance and provide the Medi-Cal plan name on the line.
Medi-Cal Insurance Name	Text	Enter the name of the Medi-Cal insurance coverage the member has (if applicable). Fill only if 'Medi-Cal' is 'Yes'. Depends on: Medi-Cal
Other Insurance - Medicare
Medicare	Checkbox	Check this box if the member has Medicare as other insurance (and enter the name of the insurance on the line provided).
Medicare Insurance Name	Text	Enter the name of the member’s Medicare insurance/plan, if Medicare applies as other insurance. Fill only if 'Medicare' is 'Yes'. Depends on: Medicare
Requesting Provider Contact Information
Office Contact Person Full Name	Text	Enter the full name of the requesting provider’s office contact person.
Office Phone Number	Text	Enter the phone number for the requesting provider’s office contact person.
Office Fax Number	Text	Enter the fax number for the requesting provider’s office.
Office Email Address	Text	Enter the email address for the requesting provider’s office contact.
Requesting Provider Facility & Identifiers
Requesting Provider Facility Name	Text	Enter the name of the requesting provider’s facility.
Requesting Provider Last Name	Text	Enter the requesting provider’s last name.
Requesting Provider First Name	Text	Enter the requesting provider’s first name.
Requesting Provider Address	Text	Enter the street address for the requesting provider or facility.
Requesting Provider City	Text	Enter the city for the requesting provider or facility address.
Requesting Provider State	Text	Enter the state for the requesting provider or facility address.
Requesting Provider ZIP Code	Text	Enter the ZIP code for the requesting provider or facility address.
Requesting Provider NPI Number	Text	Enter the requesting provider’s National Provider Identifier (NPI).
Requesting Provider Tax ID Number	Text	Enter the requesting provider or facility tax identification number.
Type of Request Selection
Retro	Checkbox	Check this box if you are submitting a retroactive request due to eligibility issues or urgent care (must be within 90 days of the date of service).
Routine	Checkbox	Check this box if the request is routine and will be processed based on Alliance clinical review.
Standing Referral	Checkbox	Check this box if you are requesting a standing referral.
Urgent	Checkbox	Check this box if the request requires a prompt decision because the member’s condition poses an imminent and serious threat to health.
Authorization Change Request	Checkbox	Check this box if you are requesting changes to an existing authorized service (and will provide the Alliance authorization number).

Prior Authorization (PA) Request Form – Adult Palliative Care (Alameda Alliance for Health) Instructions