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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 PCG
P.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