Get Centerlight Authorization Form

Filling out the Centerlight Authorization Form online is a straightforward process that can be completed in just a few steps. This guide provides clear, step-by-step instructions to help users easily navigate the form and ensure all necessary information is included.

Follow the steps to complete the form online.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Select the request type by marking either the ‘Standard Request’ or ‘Expedited Request’ box, depending on the urgency of your request.
3. Fill in the requester's details, including your name and contact number in the designated fields.
4. Provide the member's full name in the 'Member's Name' section.
5. Indicate where the patient resides by marking one of the locations: WC/RKLND, BX, MANH, QNS, BKLYN, LI, or SI.
6. Enter the member's ID number in the 'Member's ID#' field.
7. Choose the appropriate plan by selecting from the options: Direct, PACE, Select, or FIDA.
8. Input the referring provider's name in the specified area.
9. Designate whether the provider is a primary care provider (PCP) or a specialist by ticking the relevant checkbox.
10. Enter the name of the provider being referred to in the provided section.
11. Select whether this provider is in-network or out of network.
12. Include the contact number of the referred provider and the contact person's name at the office.
13. Clearly state the reason for the request in the designated area, ensuring to provide specific details and attach additional clinical information if necessary.
14. Specify the type of service requested in the corresponding field.
15. List the date(s) of service or the number of visits requested.
16. Indicate the place of service by filling in the appropriate section.
17. Provide the diagnosis/ICD9 code and procedure/CPT code as required.
18. If applicable, state the reason for an out-of-network request, providing clear justification.
19. Add any additional clinical information that may support your request.
20. Once all sections are completed, save your changes, download, print, or share the form as needed.

Complete your Centerlight Authorization Form online today for a seamless experience.