Left side of a Sample Authorization for HSPR0777 Report (Description Below)

Left Side of Form

Upper Corner: "Report: HSPR0777"

Middle Section: EI participant Information

  • Name
  • ID Numbers
  • Addresss
  • Contact infomation

Bottom Area:

  • Authorization Start Date
  • Authorized Payee
  • Authorized Type
  • Method (Individual, Group, or purchase/rent/repair)
  • Procedure (code)
  • Frequncy
  • Authorization Number
    • Date on which authorization was previous printed
  • Private Insurance

Right side of a Sample Authorization for HSPR0777 Report (Description Below)

Right Side of Form

Upper Corner: Date Report was run / printed

Middle Section: Continuation of EI participant Information

  • Birth Date
  • EI Number
  • Participant ID Number (CornerStone)
  • Telephone
  • Relationship of Contact

Bottom of Form:

  • End Date - the date range for which the specified services are authorized
  • Service
  • Place of Service: Specifies location if indicated
  • For - (Intensity, miles, minutes)
  • Status Date: Date this authorization was created or last updated

If an authorization has been cancelled or dicontinued, the status will be indicated in the area above "Status Date"