Follow the steps to fill out the form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. Fill in the member or subscriber information section by entering the ID number, last name, and first name of the member.
3. Provide the patient information by entering the last name, first name, date of birth, and sex of the patient.
4. Indicate the relationship of the patient to the member or subscriber by selecting the appropriate option, such as self, spouse, or child.
5. If applicable, indicate whether the service is related to a motor vehicle accident and provide details regarding any other insurance.
6. Specify if the other insurance is the primary provider by selecting 'Yes' or 'No'.
7. Check the service for which authorization is requested. Options include inpatient acute, outpatient therapy, radiology services, and more.
8. Fill in the admission date, first date of service, number of visits requested, requested length of stay, and authorization period.
9. Enter the primary and secondary diagnosis along with the corresponding ICD9 codes.
10. Provide the procedure details including the CPT4 code.
11. Complete the facility/provider information section, including the name of the facility.
12. Input the name, provider number, and contact information for the ordering physician.
13. Fill in the name of the person submitting the fax request.
14. Review all the information for accuracy before saving your changes, downloading, printing, or sharing the form.

Start filling out your 800 241 5308 form online today!