Get 404 848 2448

Filling out the 404 848 2448 form is essential for obtaining medical benefits for (). This guide will walk you through each section of the form, providing clear instructions to ensure accurate completion.

Follow the steps to fill out the 404 848 2448 form accurately

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering the request date. Indicate whether this is an initial authorization request or a re-authorization request by selecting the appropriate option.
3. In the 'patient information' section, fill in the patient's last and first name, patient ID number, date of birth (DOB), contact phone number, primary diagnosis, ICD-9 code(s), and patient's weight.
4. In the 'physician information' section, provide the physician's last and first name, address, city, office phone number, office fax number, physician DEA or NPI number, tax ID, state, office contact name, extension, and zip code.
5. For the 'medication information,' input the HCPCS code or drug name, the dose to be administered, the date when the member first started the drug, frequency of administration, and place of service selected.
6. Specify the duration of medication treatment and the start date for this request.
7. Check all applicable boxes in the approval criteria section according to the patient's diagnosis. Answer the questions truthfully to avoid delays.
8. In the 'physician signature' section, the prescriber or authorized representative must sign and date the form. Review the form for completeness.
9. Once all sections are filled out, save changes, and you can then download, print, or share the completed form as needed.

Complete your document online today for a smoother authorization process.