Get 18558744711

Filling out the 18558744711 form online can streamline your preauthorization request process. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the 18558744711 form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the member data section. Start with the identification number, including the three-digit prefix and the group number. Enter the member's full name, date of service, and date of birth.
3. In the procedure codes section, provide the necessary diagnosis codes, listing the primary diagnosis first. Include any relevant CPT/HCPC codes, indicating the units of measure and frequency for the supplies and services.
4. Detail any services rendered in the corresponding section, including checking one of the available boxes for provider office, outpatient facility, or inpatient facility. Provide the office or facility name, address, phone number, and NPI number(s).
5. Attach any supporting documentation that may assist in processing your request, including clinical information or letters of medical necessity. Ensure this documentation is placed on top of the submitted form.
6. In the provider data section, fill in the physician or professional provider's name, today's date, address, contact person information, and the respective phone and fax numbers.
7. Once all sections are filled out, review the form for accuracy and completeness. Save your changes, and if needed, download the form, print it, or share it as required.

Complete and submit your documents online to ensure a swift processing of your request.