Follow the steps to complete the form online

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin by entering the date of the request in the corresponding field.
3. If applicable, check the box for an urgent request. Certify that the request requires medical treatment within 24 hours.
4. Provide the member's first name, last name, member ID, and date of birth in the member information section.
5. In the servicing provider information section, fill in the NPI, tax ID, and TPI fields. Also, include the contact number and fax number for the provider.
6. List the last name and first initial or facility name, along with the contact name or requestor for the servicing provider.
7. If referring provider information is applicable, complete the fields with the NPI, tax ID, TPI, contact number, and fax number. Check the box if this is the same as the servicing provider.
8. Indicate the requested service by selecting the type, such as DME rental, therapy, or outpatient services.
9. Specify the place of service from the options provided, including office or home.
10. Ensure all DME requests include signed physician orders and that HH and rehab requests have the necessary treatment plans.
11. In the clinical review section, check the box to indicate inclusion of clinicals or plan of care.
12. Input the procedure codes and diagnosis codes as required.
13. Provide the service description, including start and end dates, and number of units or visits.
14. Enter contact information for any relevant fax numbers based on the service type requested.
15. Lastly, the requesting physician must sign the form. Remember to check the requirements for services to be approved prior to being rendered.
16. Once all the information is filled in, save your changes, download a copy for your records, or print the form as needed.

Complete your documents online to ensure prompt processing of your authorization.