Procedure Authorization (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)

Treating Facility Name

Facility Contact

Phone

Fax

State

Injured Party Information

First Name

Last Name

Date of Accident

Date of Birth

Phone

Cell Phone

Address

City

State

Zip Code

Recommended Procedure Information

Treatment Requested

Next Appt. Date

Date of Initial Visit

CPT Coding for Procedure

Description of Procedure/Treatment

Recommended # of Visits

Estimated Procedure/Treatment Cost

Attorney Information

Firm Name

Contact at Firm

Phone

Fax

State

Please include the patient-signed 2-page Red Rock Intake Form and/or clinical notes, if applicable.

Questions? Call us at (877) 362-6077