The Brown & Toland prior authorization form is a one-page fax request a provider completes before delivering certain services, procedures, or equipment to a patient enrolled with Brown & Toland Physicians (now operating under Altais, a Blue Shield of California subsidiary). Download the current version from the Altais compliance resources page at altais.com/compliance-resources/, fill in the patient, provider, and coding sections, attach clinical records, and fax the packet to Brown & Toland Referral Services at 415-972-6012 or submit it through the Altais Link portal.
Where to Download the Current Form
Altais hosts two documents on its compliance resources page. The link labeled “Paper Authorization Form” opens the treatment authorization request, and the link labeled “Prior Authorization List” shows which services require approval before being performed. Bookmark the compliance resources page itself rather than saving a direct PDF link. Altais updates the forms periodically, and older versions can be returned unprocessed.
You may see either Brown & Toland or Altais branding on current paperwork. Both refer to the same organization.
Filling Out the Form
The form has four working sections: patient information, requesting provider, servicing provider, and clinical coding. Work through them in that order. The utilization management team returns incomplete forms rather than guessing at blank fields.
Patient Information
Enter the patient’s full legal name exactly as it reads on the insurance card, along with the date of birth and member ID number. The member ID is printed on the front of the health plan card and is not the same as a Social Security number. A single transposed digit routes the request to the wrong file and comes back as “member not found.”
Requesting Provider
List the requesting physician’s name, specialty, and ten-digit National Provider Identifier. The form also asks for a direct phone number, an office contact, and a fax line so reviewers can reach the office if clinical questions arise. If the requesting physician is not the patient’s primary care provider, fill in the PCP’s name, phone, and fax in the separate PCP fields.
Servicing Provider and Facility
When a different provider or a specific facility will perform the service (a surgeon, an imaging center, a skilled nursing facility), enter that provider’s name, NPI, and contact information in the servicing provider section. Leave it blank only if the requesting physician will perform the service themselves. A missing servicing provider is one of the most common routing delays.
Diagnosis and Procedure Codes
At least one ICD-10 diagnosis code and at least one CPT or HCPCS procedure code are required; both fields are marked “REQUIRED” on the form. ICD-10 codes describe the medical condition. CPT and HCPCS codes identify the service, procedure, or durable medical equipment being requested. For each procedure code, include the number of units and a brief description. Drug requests have separate fields for drug name, dosage, method of delivery, and frequency or duration.
Use the most specific code available. A generic or “unspecified” ICD-10 code paired with a high-cost procedure is a common reason reviewers send a request back for more information. If a CPT code is unlisted, add a written description of exactly what the procedure involves.
Clinical Documentation to Attach
The form warns in bold that incomplete information may delay processing. Fax supporting records with every request. At minimum, include:
- History and physical or consultation notes explaining why the service is needed for this patient.
- Recent laboratory results that support the diagnosis.
- Diagnostic testing and imaging results (MRIs, CT scans, X-rays) that justify the next step in care.
- Prior treatment history, particularly for surgical or high-cost requests where the reviewer needs to see that less invasive options were tried first.
The review team evaluates requests against clinical guideline sets such as MCG (formerly Milliman Care Guidelines) or InterQual, which are updated annually. Framing clinical notes around the criteria that apply to the requested service speeds up approval. California law requires the plan to disclose the criteria it is applying if you ask.
How to Submit
By Fax
Fax the completed form and all supporting documents to Brown & Toland Referral Services at 415-972-6012. Use a cover sheet that identifies the submission as a prior authorization request and lists a callback number. Keep the fax confirmation page. The timestamp is your proof of when the request entered the queue, which matters for the statutory review clock.
Through the Altais Link Portal
Offices with access to the Altais Link portal (epiclink.brownandtoland.com) can submit electronically. If your practice does not have credentials, a provider at the practice can request them through the portal’s account request page. The portal accepts the completed PDF plus supporting attachments and generates a confirmation on submission. Electronic submissions tend to move through intake faster because they skip the manual scanning step a faxed packet requires.
How Long the Decision Takes
California Health and Safety Code Section 1367.01 sets the deadlines. The clock starts when the plan has all the information it reasonably needs to decide.
- Routine requests: the plan must approve, modify, or deny within five business days.
- Urgent requests (imminent and serious threat to life, limb, or major bodily function, or where the standard timeline would be detrimental to the patient’s health): 72 hours.
If the reviewer needs more clinical information, the routine timeline can be extended by up to 14 calendar days from the date of the original request, but only if the treating provider notes that the delay will not harm the patient.
Prescription drug prior authorizations run on a separate California regulation: 72 hours for non-urgent drug requests and 24 hours for exigent circumstances. For Medicare Advantage members, federal rules apply as of January 1, 2026, requiring plans to decide routine requests within seven calendar days and urgent requests within 72 hours.
After the Decision
The plan notifies both the requesting provider and the patient. An approval includes an authorization number and a date range for performing the service. Schedule the procedure inside that window, because an expired authorization requires a new request. Pending requests can be tracked through the Altais Link portal.
A denial or modification notice must state the specific clinical reasons and explain how to appeal. The criteria the plan relied on must be provided free of charge on request.
Common Mistakes That Delay Approval
Most prior authorization problems trace back to a handful of preventable errors. The form warns that incomplete submissions may result in an adverse determination, meaning a denial for insufficient information rather than a true clinical denial. That forces a resubmission instead of a cleaner appeal path.
- Wrong or missing member ID. Verify the number against the current insurance card at every visit.
- Unspecified diagnosis codes. A generic ICD-10 when a more specific one exists raises an immediate flag on surgical or high-cost requests.
- No supporting clinical notes. A form without history and physical notes or relevant labs almost always triggers a request for additional information, pausing the clock.
- Expired or wrong form version. Pull the form fresh from the compliance resources page rather than reusing an older PDF.
- Missing servicing provider information when someone other than the requesting physician will perform the service.
A short pre-fax checklist built around these five items prevents more delays than any other step in the workflow.
If the Request Is Denied
Two levels of review are available before litigation. File an internal appeal with the plan first; for ERISA-governed plans, you have at least 180 days from the denial notice. The plan must decide urgent appeals within 72 hours, pre-service appeals within 30 days, and post-service appeals within 60 days, and it generally cannot charge a fee to file.
If the internal appeal does not resolve the issue, or 30 days pass without a resolution, California patients can request an Independent Medical Review through the Department of Managed Health Care. IMR covers denials based on medical necessity or on the plan’s view that a treatment is experimental. It is not available to Medicare enrollees, Medi-Cal fee-for-service members, members of self-insured employer plans, or workers’ compensation disputes. The application form and submission options are on the DMHC website.