Get Video Capsule Endoscopy Authorization Form - Tufts Health Plan

Completing the Video Capsule Endoscopy Authorization Form is essential for securing coverage from Tufts Health Plan. This guide provides a step-by-step approach to help you fill out the form accurately and effectively online.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Fill in the patient’s name and date of birth (DOB) in the designated fields. Ensure accuracy as this information is critical for identification.
3. Enter the date of request and patient ID number. These details help track the authorization request throughout the process.
4. Complete the diagnosis code (Dx/ICD-9) as well as the procedure code(s). Ensure to check the correct codes that apply to the patient's condition.
5. Provide the provider's name, provider ID number, and contact information, including the provider's phone and fax numbers. This ensures that Tufts Health Plan can contact the provider for any clarifications.
6. Obtain the provider's signature in the designated area. This signifies that the provider has completed and reviewed the form.
7. Review all sections for completeness and clarity. Omissions, generalities, or unclear handwriting may result in the form being returned for corrections.
8. Once all fields are accurately filled out, save any changes made to the document. You can choose to download, print, or share the form as necessary.

Complete your Video Capsule Endoscopy Authorization Form online today for a smoother authorization process.