Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the authorization number in the designated field at the top of the form. This number is essential for tracking your submission.
3. Fill in the start and end date fields related to the requested services. Ensure these dates align with your active enrollment period.
4. Provide your name, phone number, and any necessary comments in the specified sections. This information helps in processing your request.
5. In the member information section, input the member's name, date of birth, and member identification number. Make sure all details are accurate and clearly presented.
6. If applicable, indicate whether the member is a minor and include the parent or guardian's name in the required field.
7. Complete the procedure/service information section by entering required codes like ICD-9 and CPT codes. Attach any necessary clinical information as specified.
8. Fill out the referring provider's information, including name, specialty, and contact details. Double-check for correctness.
9. In the referred to section, provide details of the provider or physician who will be receiving the request.
10. Review all sections for completeness and accuracy before finalizing your form.
11. Once everything is complete, save changes, download, and if necessary, print or share the form as needed.

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