Follow the steps to successfully fill out the form online.

1. Press the ‘Get Form’ button to access the Oticon Medical Reimbursement Support Services Intake Form and open it in your chosen editor.
2. Begin by entering the patient information. Fill in the patient's name, date of birth, gender, address, and contact numbers in the respective fields.
3. Specify the patient’s parent or legal guardian information if applicable. This includes their name and relationship to the patient.
4. Complete the insurance information section. Input the primary and, if available, secondary insurance details such as the insurance company names, phone numbers, member IDs, and subscriber information.
5. Provide the physician's information, ensuring to fill out the physician's name, office contact details, and their address.
6. Fill out the audiologist's information similarly to the physician details, including the audiologist's name and contact information.
7. Select the service requested by checking the appropriate box, indicating if it is a repair authorization, prior authorization for surgery, prior authorization for equipment and supplies, or other.
8. If applicable, fill out the section for equipment and supplies needed. Include the diagnosis and list any relevant ICD-10 diagnosis codes.
9. For surgical prior authorization requests, complete the required facility and surgery information, including the surgery date and relevant diagnosis and surgical codes.
10. In the Medicare information section, provide necessary dates and certifications as required, making sure to certify the accuracy of the medical necessity information.
11. Read through the notice of privacy practices and acknowledgments sections, ensuring that all required acknowledgments are signed and dated.
12. After filling out all sections, review the form for completeness and accuracy before saving your changes. You can then download, print, or share the completed form as needed.

Take the next step and complete your form online today.