Get Bridgeway Boosters

Filling out the Bridgeway Boosters form is a crucial process for requesting authorization for services. This guide will assist you in completing the form accurately and efficiently.

Follow the steps to complete the Bridgeway Boosters form online.

1. Click the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin by providing member information. Fill out the last name, first name, and address (including city, state, and zip code). Indicate Medicare eligibility by marking either Part A or Part B, or specify if they are not Medicare eligible.
3. Enter the date of birth and AHCCCS ID number for the member. Include a contact telephone number and specify the primary language spoken.
4. In the section regarding additional insurance coverage, provide the insurance company name and insured ID number. Indicate whether the requested service is approved by the member's primary or additional insurance.
5. For the requesting provider information, fill in the provider's name, address, and provide a signature if required. Include the contact person’s extension and telephone number, along with the fax number.
6. Complete the information for the referred provider or facility, including their full name and specialty. Provide the anticipated date of service.
7. Detail the service request by selecting the service setting, and entering telephone and fax numbers as needed. Fill in the codes and descriptions, including ICD codes, CPT/HCPC codes, and service types.
8. Provide physical details, such as height and weight, and specify the number of times per week and number of weeks for therapy services, if applicable.
9. Include any comments or additional information in the designated comments section.
10. Finally, review the form for completeness and clarity. Once the form is accurately filled out, save your changes, and if needed, download, print, or share the completed document.

Complete your Bridgeway Boosters authorization requests online today.