Follow the steps to fill out the form online:

1. Click the ‘Get Form’ button to access the authorization request form and open it in your preferred editor.
2. Begin by entering the date of your request in the designated space at the top of the form.
3. Fill in the member's name, date of birth, member ID number, diagnosis, and the corresponding ICD 9 code.
4. Specify the requested services along with the CPT or HCPCS code in the appropriate fields.
5. Indicate the type of service required by selecting from the options provided, ensuring you provide accurate details regarding the place of service and facility name.
6. Input the requesting provider’s tax ID number, name, and office contact details, including the office phone number and fax number.
7. Complete the section regarding the place of service or facility, including their phone number and fax number.
8. Address specific service requirements by filling out any additional questions pertaining to clinical trials, implants, or robotic assistance in surgery.
9. Indicate the requested date of service and provide any necessary clinical or additional information that supports the request.
10. Review all fields to ensure accuracy and completeness before saving changes, downloading, printing, or sharing the form as needed.

Submit your authorization request online today to ensure timely processing.