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Get La Care Authorization Form
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How to fill out the La Care Authorization Form online
Filling out the La Care Authorization Form online can streamline the pre-authorization process for health services. This guide will provide you with clear, step-by-step instructions tailored to help you complete the form accurately and efficiently.
Follow the steps to fill out the La Care Authorization Form online
- Press the ‘Get Form’ button to access the La Care Authorization Form and open it in your preferred online editor.
- Begin by checking one of the options that applies to the type of request: 'Healthy Families', 'Out-of-network', or 'PPG'.
- Enter the patient's information in the designated fields, including their full name, date of birth, member ID or Social Security number, address, and phone number.
- Indicate whether the service is In-network or Out-of-network, and select the appropriate urgency category: 'Urgent' (within 72 hours) or 'Routine' (within 5 calendar days).
- In the 'Referral - Service Type Requested' section, select the type of service being requested, such as 'DME', 'Home Health', or 'Surgical Procedure', and provide any additional details if necessary.
- Fill in the information regarding the requesting provider, including their name, specialty, phone number, address, and fax number.
- Next, provide details about the provider who will perform the requested service, including their name, specialty, phone number, address, and fax number.
- In the 'Diagnosis/Procedure Information' area, clearly document the necessary codes (ICD-9, CPT, and HCPCS) along with their descriptions.
- Provide clinical indications for the request, including pertinent past medical treatments, physical findings, and attach any relevant medical records and test results.
- Print your name, sign, and date the form as the requesting provider, ensuring all required fields are appropriately filled.
- Finally, review all information for accuracy, then save changes, download, or print the form for submission to L.A. Care UM Department via fax.
Complete your documents online swiftly and easily. Start filling out the La Care Authorization Form now!
Related links form
To reach L.A. Care for authorization inquiries, you can call their dedicated helpline at 1-888-839-9909. This number can assist you with information regarding the La Care Authorization Form, questions about your benefits, and other preauthorization steps. Having this contact information handy can make your authorization process smoother and more efficient.
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