Insurance Prior Authorization Request

Matia Mobility has partnered with Tamm Net to help streamline the process of securing insurance coverage, making it easier, faster, and more efficient for you to get the approvals you need. Please fill out the form below as completely as possible and one of our insurance experts will be in touch with you.

Matia Mobility Prior Authorization Request Form

PreAuthForm

Provider Information

Physician Name

Name of Practice

Office Address

Address Line 1

Address Line 2

City

State

Zip Code

Clinical Contact Name

Contact Email

Office Phone

Office Fax

Patient Information

Patient Name

Phone

Date of Birth

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Information

Type of Coverage

Medicare

Medicaid

Commercial

Worker’s Comp

Claim #

Date of Injury

Primary Insurance

Policy Number

Insurance Company Claims Phone Number

Fax Number

Group Number

Subscriber Name

Secondary Insurance

Do you have Secondary Insurance?

Yes

Secondary Insurance

Policy Number

Phone/Mobile

Fax Number

Group Number

PTAN Number

Subscriber Name

Disclaimer: Coverage and Authorization Services are provided for your convenience only and are not intended to be a recommendation regarding clinical practice, or any representation or warranty regarding payment or as a guarantee of payment by any payer. It is the responsibility of the provider to ensure that appropriate claims and charges for services that were rendered are submitted. TAMM Net is not and shall not be liable for the cost of the patient’s medical treatment under any circumstance. TAMM Net provides assistance on prior authorization requests for FDA approved or cleared indications. Where reimbursement is requested for a use of a product that may be inconsistent or not expressly specified in the FDA cleared or approved labeling (e.g., Instructions for use, operator’s manual or package insert) consult with your billing advisors or payers for advice on handling such billing issues. Some payers may have policies that make it inappropriate to submit claims for such items or related services. Contact your Medicare contractor or other payer for interpretation of coverage, coding, and payment policies.