Medical Indemnity Fund
- Form is also available in Portable Document Format (PDF)
Prior Approval Request Form
Request being made on behalf of (Name of Enrollee): ___________________________________
MIF Enrollee ID: NYS__ __ __ __ __ __ __ __ __
Name of Person(s) Submitting Request: _____________________________________________
Signature of Person(s) Submitting Request: __________________________________________
Relationship to Enrollee: _________________________________________________________
Date Request Submitted: _____________________
ITEM AND/OR SERVICES REQUESTED: (services you are requesting)
I am requesting approval of the following item(s) and/or services from the New York State Medical Indemnity Fund:
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PROVIDER(S) SUPPLYING ITEM AND/OR SERVICES REQUESTED:
Name | Address | Phone Number |
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REASON FOR REQUEST:
The reason(s) for this request is/are:
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Please provide a Letter of Medical Necessity for each service and/or item requested from the appropriate healthcare provider for the enrollee. The letter should include any specifications that the provider recommends.
If a Letter of Medical Necessity is not included with this request, one will be sought by the enrollee´s Case Manager from the appropriate healthcare provider for the enrollee.
Please send this request form to:
Medical Indemnity Fund c/o PCGP.O. Box 7315, Albany, NY 12224
You can also send by fax to: 518–344–1293 or scan and email your Case Manager.
If you communicate by e–mail, you agree to be fully responsible if sending protected health information by unsecured means