Children's PA Process Weekly Reporting Form


Please enter your name, phone number, and e-mail address below so Kenny Whitlock may contact you if there are any questions about the data entered.

First Name:
Last Name:
Phone:
E-mail:
Start Date of Data (mm/dd/yyyy):
Ending Date of Data (mm/dd/yyyy):
Center:


Number of requests for PA submitted to First Health:
Number of requests approved:
Number approved within 5 days:
Number approved but after 5 day time frame:
Number denied within 5 days:
Number denied but after 5 day time frame:
Number pending:
Number pending over 5 days:

Direct questions about the data you are entering to: Kenny Whitlock at (501) 372-7062.