Follow the steps to complete the authorization form online with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Input the patient’s name accurately in the designated field, ensuring it matches the name on their insurance documents.
3. Enter the patient's date of birth (DOB) in the format requested, ensuring that it reflects the accurate birthdate.
4. Fill in the fax sender's name, ID number, and contact details accurately for any further communication.
5. Indicate whether the fax line being used is HIPAA secure by checking the appropriate box.
6. Detail the requesting physician’s information and home care agency name, ensuring all details are correct.
7. Specify the dates of service requested, noting that these should not exceed 180 days.
8. Provide a brief description of the patient’s diagnosis along with the relevant ICD-9 code(s).
9. In the services requested section, specify the services needed and include the corresponding HCPCS codes for skilled nursing, physical therapy, occupational therapy, and home hospice as applicable.
10. Indicate whether there is any other insurance coverage by selecting 'Yes' or 'No', and if applicable, provide the name of the insurance company, subscriber, and policy/group number.
11. Fill in the number of visits requested, ensuring the number aligns with any service limits specified.
12. For UnitedHealthcare Great Lakes use only, leave the fields below the line blank, as instructed.
13. Attach any clinical information relevant to the requested service, as specified, including treatment documents and relevant forms.
14. Review the entire form for completeness and accuracy before submitting.
15. After completing the form, you can save your changes, download, print, or share the completed document as needed.

Start filling out the Harvard Pilgrim Health Prior Authorization For Medication online today.