Follow the steps to successfully complete the authorization request form.

1. Click ‘Get Form’ button to access the document and open it in your preferred viewer.
2. Enter the date when the request was received. This is typically filled in by the office handling the authorization.
3. Next, fill in the date the request is being submitted. This helps keep track of the timeline of the request.
4. Provide the name and contact information of the office contact person. This ensures the reviewer can easily reach out for any clarifications.
5. Include the referring physician's first and last name, their specialty, phone number, and fax number. Accurate information is crucial for communication.
6. Indicate the facility and location where the procedure will take place. This should be where the service is scheduled.
7. Complete the patient information section by entering the patient's name, health plan/group name, member ID number, date of birth, and phone number. Ensure this data is precise for the patient's authorization.
8. Specify the state where the patient is located. This may be relevant for regulatory purposes.
9. List the procedure(s) ordered along with their CPT codes, if available. This helps ensure that the necessary services are properly documented.
10. Provide clinical indications for the ordered exams, detailing signs, symptoms, severity, duration, and working diagnosis. Supporting documents such as medical notes can be attached if needed.
11. Fill in the ICD-9 code, which is required for further processing of the request.
12. Add any relevant prior tests, treatments, or additional information that may assist the reviewer.
13. Indicate the best day, time, and phone number for the reviewer to contact the ordering physician. This facilitates effective communication.
14. Complete the submission date and ensure the signature field is signed by the person requesting the authorization.

Complete your prior authorization request form online today and ensure seamless processing of your request.