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Get Kyhealth Choices Prior Authorization Form

KyHealth Choices Prior Authorization Call Checklist Prior to calling or faxing this request to prior authorize services please complete the following information for each Medicaid member when requesting services. By completing this form our representatives will be able to process your request more quickly. We thank you for your assistance. Clinical staff should make the Prior Authorization request. Review the attached list to see if service requires prior authorization and add below. All fields are required to process the Prior Authorization request. This request does not guarantee these services will be authorized* Member Last Name Member Address City Member Middle Initial Member Medicaid Zip Code Responsible Party for Member Under Age of ID Number Member Date of Birth Ordering Provider Name should enter license number and state Facility Name and Address Facility s Medicaid Number Facility Contact Person Name Date s of Service Diagnosis Codes Clinical Criteria Procedure Codes Once this form is complete you may call 1-800-292-2392 for medical prior authorizations excluding home health. By completing this form our representatives will be able to process your request more quickly. We thank you for your assistance. Clinical staff should make the Prior Authorization request. Review the attached list to see if service requires prior authorization and add below. Clinical staff should make the Prior Authorization request. Review the attached list to see if service requires prior authorization and add below. All fields are required to process the Prior Authorization request. This request does not guarantee these services will be authorized* Member Last Name Member Address City Member Middle Initial Member Medicaid Zip Code Responsible Party for Member Under Age of ID Number Member Date of Birth Ordering Provider Name should enter license number and state Facility Name and Address Facility s Medicaid Number Facility Contact Person Name Date s of Service Diagnosis Codes Clinical Criteria Procedure Codes Once this form is complete you may call 1-800-292-2392 for medical prior authorizations excluding home health. By completing this form our representatives will be able to process your request more quickly. We thank you for your assistance. Clinical staff should make the Prior Authorization request. Review the attached list to see if service requires prior authorization and add below. All fields are required to process the Prior Authorization request. This request does not guarantee these services will be authorized* Member Last Name Member Address City Member Middle Initial Member Medicaid Zip Code Responsible Party for Member Under Age of ID Number Member Date of Birth Ordering Provider Name should enter license number and state Facility Name and Address Facility s Medicaid Number Facility Contact Person Name Date s of Service Diagnosis Codes Clinical Criteria Procedure Codes Once this form is complete you may call 1-800-292-2392 for medical prior authorizations excluding home health.

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