Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to obtain the authorization form and open it for editing.
2. Begin with the 'Person completing the form' section. Enter your name, indicate whether you are working at a primary care provider (PCP) office or a specialist office, and fill in the date, phone number, and fax number.
3. In the 'Member name' section, enter the last name, first name, middle initial, date of birth, and subscriber ID of the member for whom you are requesting authorization.
4. Fill out the 'PCP name' and 'Clinic name' fields to identify the primary care provider.
5. In the 'Provider names' section, input the specialist's name, their fax number, the clinic name, the facility name, and the tax identification number (Tax ID) of the facility.
6. For the 'Diagnosis (Dx) / Procedure Information', provide the primary diagnosis and its corresponding code, the primary procedure with its CPT/CDT-4 code, and any secondary diagnoses or procedures if applicable.
7. Respond to the question regarding comorbid conditions. Mark 'Yes' or 'No', and if 'Yes' is selected, describe the condition(s) and provide the diagnosis code along with a narrative explanation.
8. Complete the 'Level of care requested' section by indicating whether the request is for a hospital inpatient stay, the anticipated admit date, and the expected number of days.
9. Make sure to attach relevant chart notes with your authorization request as mentioned in the instructions.
10. After ensuring all fields are correctly filled out, you can save the changes, download the form for your records, print a copy, or share it as needed.

Start completing your OR CareOregon Inpatient - Prior Authorization Form online today!