Get 844 522 5282

Filling out the 844 522 5282 Authorization Request Form online can be straightforward with the right guidance. This form is essential for requesting healthcare services and should be completed accurately to ensure processing without delays.

Follow the steps to complete the 844 522 5282 form online.

1. Press the ‘Get Form’ button to obtain the form and open it for editing.
2. Enter the date of request in the designated field.
3. Provide your contact information, including your name, phone number, extension, and fax number.
4. Fill in the member ID number, first and last name, and date of birth.
5. Input the requesting provider's name, ensuring to indicate if the request was made by a primary care provider (PCP) and provide their contact information.
6. Select the applicable request type(s) and fill out any requested information related to out-of-network (OON) specialist referrals.
7. Complete the performing provider information, including their name, specialty, NPI number, and tax ID number.
8. Provide details for the type of service requested and any applicable information fields.
9. For durable medical equipment (DME) or prosthetics, include the supplier name and equipment details, along with the necessary HCPCS codes.
10. Describe the diagnosis and procedure information along with the corresponding ICD and CPT/HCPCS codes.
11. Fill out the service dates, including admission and expected discharge dates if applicable.
12. If requesting expedited review, confirm that the criteria for expedited status are met and obtain the physician’s signature.
13. Review the entire form for accuracy and completeness before proceeding to save, download, and print your submission.

Complete your documentation online to ensure a smooth processing experience.