Get Eeounps002fm - Authorization Request Form - Employers

Completing the EEOUNPS002FM - Authorization Request Form - Employers is a crucial step for initiating authorization for necessary medical services. This guide will provide you with clear and detailed instructions to help you fill out the form accurately and efficiently.

Follow the steps to complete your authorization request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient and claim data: fill in the date of the request, patient name, claim number, social security number, date of injury, and body part(s) affected.
3. Fill in the employer information, including the name of the employer, and indicate the patient’s gender and age. You will need to specify whether the patient is currently working.
4. In the authorization data section, provide the requesting physician's name, tax ID, diagnosis, and the required ICD-9 code. Ensure the requested service(s), procedure(s), or diagnostic test(s) are clearly detailed and provide the corresponding CPT code.
5. Include information about the surgeon, assistant, and anesthesia group, as well as the facility where the service will be performed. Specify the requested length of stay for the patient.
6. Complete the provider contact information, including the return fax number, phone number, and email address where the authorization should be sent.
7. Make sure to attach relevant medical reporting and objective findings to support the request.
8. Once all sections are completed, review the information for accuracy. You have the option to save changes, download, print, or share the completed form as needed.

Complete your authorization request online today for a streamlined experience.