Procedure Authorization Request (Physicians)

Please complete the following form to request authorization of follow-up visits and/or procedures to be funded on a Red Rock lien or LOP.

Step 1: Fill out the form below to include cost estimate.

Step 2: Attach the clinical notes and Red Rock intake form from initial patient visit, if applicable.

Step 3: Submit.

Requesting Facility Information (Please fill out the form completely)







Injured Party Information












Recommended Procedure Information








Attorney Information







SUBMIT FORM VIA EMAIL OR FAX TO:

preauth@redrockdiagnostics.com

Fax: (702) 463-4259

Questions? Call us at (877) 362-6077

Red Rock Diagnostics, LLC ∙ P.O. Box 26119 Las Vegas, NV 89126