Get Kyhealth Choices Prior Authorization Form

Filling out the Kyhealth Choices Prior Authorization Form online can streamline the process of obtaining necessary services through Medicaid. This guide will provide you with clear instructions for each section of the form and help ensure that you complete it accurately.

Follow the steps to fill out the form seamlessly.

1. Use the ‘Get Form’ button to download the Kyhealth Choices Prior Authorization Form. Open it in your preferred document viewer.
2. Begin by entering the member's last name in the designated field. Ensure that all required fields are completed accurately to avoid processing delays.
3. Fill in the member's first name, middle initial, date of birth, and Medicaid ID number. These details are crucial for identifying the correct Medicaid member.
4. Provide the member's complete address, including the city and zip code. This information is necessary for correspondence regarding the authorization request.
5. If the member is under the age of 18, identify the responsible party for that member in the specified field.
6. Enter the ordering provider's name and Medicaid number. If the provider is not a Medicaid provider, use their license number along with the state information.
7. List the name and contact information for the ordering provider’s contact person, including their phone number, making sure to follow any formatting requirements.
8. Provide the facility name and address where services will be provided. Include the facility’s Medicaid number and contact person's details as required.
9. Document the date(s) of service along with the appropriate diagnosis and procedure codes. These codes are essential for correctly categorizing the requested services.
10. Review all the information entered for accuracy before finalizing the form. Once confirmed, you can save your changes, download, print, or share the form as needed.

Complete your documentation online today to ensure timely processing of your prior authorization requests.