Get Gbg Assist Pre-authorization Form 2018-2025

Filling out the GBG Assist Pre-Authorization Form is an essential step in ensuring that you receive the necessary medical treatments without unnecessary financial penalties. This guide will walk you through each section of the form, providing clear instructions to help you complete it accurately and efficiently.

Follow the steps to complete the pre-authorization form online

1. Click the ‘Get Form’ button to obtain the form and access it within your preferred editor.
2. In the 'Patient Information' section, enter the patient's full name, policy number, GBG ID number, date of birth, employer (if applicable), complete address, country, phone number, fax number, and email address.
3. Navigate to the 'Pre-Authorization Request' section. Here, fill in the procedure or treatment name, indicate whether surgery is required, and specify the type of anesthesia needed. Provide the expected surgery date and whether the patient will be admitted overnight.
4. If the request is for maternity admissions, indicate the anticipated type of delivery (vaginal or cesarean section). Additionally, enter the estimated costs for the physician/surgeon and hospital/facility.
5. Document the date of injury, illness, or accident and the first date treatment was received for the condition. Describe the treatments received, including relevant dates.
6. Answer the questions regarding the treatment's relation to the patient's occupation, automobile accidents, or any other type of accident. Provide details if applicable.
7. Indicate whether the patient has previously received diagnosis or treatment for the same condition and provide relevant details if any.
8. Confirm if the patient is also covered by other health plans, Medicare, or a no-fault auto carrier, providing any necessary details.
9. In the 'Hospital/Physician Information' section, enter the names and tax ID numbers for both the hospital/facility and the physician/provider, along with their contact details.
10. Finally, complete the 'Authorization' section by typing your name to sign electronically. Ensure you acknowledge the legal implications of any misrepresentation.
11. Once you have filled out all necessary fields, remember to save your changes. You can then download, print, or share the completed form as needed.

Complete your GBG Assist Pre-Authorization Form online today to ensure timely processing of your medical procedure.