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Treatment Authorization
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877-362-6077
PT Authorization Request
PT Authorization Request
Initial Request
Follow Up Request
Requesting Facility Information (Please fill out the form completely)
Treating Facility Name
Facility Contact
Phone
Email
Fax
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Injured Party Information
First Name
Last Name
Date of Accident
Date of Birth
Email
Phone
Cell Phone
Address
City
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Zip Code
Recommended Therapy Information
Date of Initial Visit
Next Appt. Date
Recommended # of Visits
Attorney Information
Firm Name
Contact at Firm
Phone
Email
Fax
State
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CA
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CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
PR
VI
GU
AS
Please upload the signed physician referral form here, or fax to: 702-463-4259
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
Contact Information