Get Prior Authorization Form - Suburban Health Organization

Completing the Prior Authorization Form for the Suburban Health Organization is an essential step in ensuring that necessary medical services are approved efficiently. This guide provides clear, step-by-step instructions to help users navigate the online form with confidence.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to obtain the Prior Authorization Form and open it for editing.
2. Fill in the patient’s name, date of birth, and identification number at the top of the form.
3. Indicate the patient’s insurance plan, primary care provider's name, phone number, and fax number.
4. Provide the diagnosis along with the corresponding ICD-9 code(s) to ensure accurate representations of the patient's condition.
5. Enter the procedure required and the CPT-4 code(s) associated with it.
6. Select whether the services are outpatient, inpatient, or observation by marking the appropriate box.
7. Indicate the vendor or facility where the service will be provided and the date of the requested service.
8. Specify the number of days or visits requested for the treatment.
9. Include referral details, such as the name and contact information for the referring party.
10. Complete the section for the person submitting the request, including their phone number and fax number.
11. For specialty referrals, detail the specialist's name, their specialty, and any additional information about requested services.
12. Provide any additional medical information that may assist in processing the request.
13. If applicable, indicate if the request is for a non-participating provider and explain why they cannot provide the service.
14. Review the completed form for accuracy and completeness to avoid delays in processing.
15. Finally, save your changes, download, print, or share the completed form as needed.

Start completing your documents online today!