Get Prohealth Prior Authorization Request Form - Community Health ...

Completing the ProHealth Prior Authorization Request Form accurately is essential for obtaining necessary medical services. This guide provides clear, step-by-step instructions to help you fill out the form online, ensuring a smooth submission process.

Follow the steps to complete the form online:

1. Locate the ‘Get Form’ button to access the request form. Press the button to open the document in your online editor.
2. Begin by filling out the patient information section. Include the patient's full name, date of birth, insurance ID number, and insurance plan.
3. Provide details about the primary care provider (PCP), including their name, phone number, and fax number.
4. In the diagnosis section, accurately describe the condition and include the appropriate ICD-9 code.
5. Indicate the procedure to be performed, along with the relevant CPT-4 code.
6. Fill in the vendor or facility information and specify the requested service.
7. Enter the date of the requested service and the total number of visits or days required.
8. Complete the referral section by providing the name and contact information of the individual making the referral.
9. In the specialty referral section, include the specialist's name, specialty, and the type of service requested.
10. If applicable, check the appropriate boxes to indicate if any documentation is attached or additional medical information is required.
11. Finally, review all information for accuracy and completeness. Save your changes, and then download, print, or share the completed form.

Start completing your ProHealth Prior Authorization Request Form online today!