Page 41 - MyOwnSkin-Hensler 6_2020

BIOLAB SCIENCES, INC.

Medical Prior Authorization Portal Consent Form

The following form is designed to give permission to BioLab Sciences, Inc., (BLS) to obtain prior
authorization for medical services to be rendered with BLS products on your patient at your practice,
through your provider portal.

As of ___/____/____, the following permission is granted access to the medical authorization portal for
BLS by: ______________________________ and will remain in effect until this agreement is
terminated.

1. BLS, will require access to your medical authorization portal(s) as a user assigned with a
user-name and password for Availity, Optum, and etc.

2. BLS, will provide an authorization form that will need all required fields completed. If anything is
missing or incomplete that prevents accessing the practice’s portal and having all of the patient
information to enter, completely, the form will be returned to seek additional information and
the prior authorization process will not proceed.

3. BLS requests that a legible copy of the patient’s insurance card is provided including a copy of
the front and back of the card.

4. BLS, requests that the appropriate amount of time is accounted for, to complete the prior
authorization to be reviewed within the portal.

• Q4205 Membrane Wrap 7 days
TM
• Q4206 Fluid Flow 5 - 7 days
TM

• Q4226 My Own Skin 7 - 15 days
TM
The indicated service timeframes above are based on the insurance company’s request for a medical
review, clinical notes requested, and or a peer-to-peer review.

If a peer-to-peer review is requested by the insurance company, it is the responsibility of the office staff
of the medical practice to call the insurance company and set the appointment as the doctor’s schedule
and availability is very important to know and the provider must understand that any missed
appointments will trigger the case to close and the authorization request process will have to start over
from the beginning.

Practice Name: ______________________________

Tax ID #: ____________________________________ NPI #:__________________________________

User: _______________________________________ Password: ______________________________

Signature: ___________________________________ Date: ____/____/_______

Name: ___________________________________

Email form to: preauth@biolabsciences.net