Out of Province Request Script

Hi, my name is [YOUR NAME], and my provincial health number is [HEALTH NUMBER]. My physician, Dr. [PHYSICIAN NAME], has recommended I receive [NAME OF SERVICE/PROCEDURE] at [FACILITY NAME, PROVINCE], because [REASON — e.g. "this service is not currently available in my home province" or "the wait time locally poses a documented health risk"]. I'd like to confirm: 1. Does this service require prior authorization for out-of-province coverage? 2. What is the process and expected timeline for approval? 3. What rate will be covered, and will I be responsible for any difference in cost? 4. Is there a reference number or file number I should use for this request? Could you also let me know if there's a written form my physician needs to submit, and where it should be sent? Thank you — could I get your name and a reference number for this call, for my records?

[Physician Letterhead] Date: [DATE] RE: Request for Prior Authorization — Out-of-Province Care Patient: [PATIENT FULL NAME] Health Number: [HEALTH NUMBER] To the Out-of-Province Coverage Office, I am requesting prior authorization for my patient, [PATIENT NAME], to receive [NAME OF SERVICE/PROCEDURE] at [FACILITY NAME AND PROVINCE]. This request is made because [clinical reason: unavailable locally / wait time risk / other documented reason]. Relevant clinical details: [Brief diagnosis and clinical justification, 2-3 sentences] Anticipated date of service: [DATE] Referring physician contact: [NAME, PHONE, FAX/EMAIL] Please confirm approval, applicable coverage rate, and any patient-responsibility amount in writing prior to the scheduled date, given the timeline involved. Sincerely, [Physician Name, Credentials, License Number]