Get Prior Authorization Form - Common Ground Healthcare Cooperative

Filling out the Prior Authorization Form is a crucial step in ensuring that your medical services are approved in a timely manner. This guide will provide you with clear instructions on how to complete the form online, ensuring that all necessary information is included to avoid delays in processing.

Follow the steps to fill out the Prior Authorization Form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Start by filling in the 'Requesting Provider Name' and 'Requesting Provider Tax ID' in the designated fields. This information identifies the healthcare provider making the request.
3. Complete the 'Address' section with the provider's full address, ensuring accuracy to aid in processing. Then, enter the 'Name of Facility' and its corresponding 'Facility Address.'
4. Indicate the 'Anticipated Date of Service' and select whether it is an 'Inpatient' or 'Outpatient' service by checking the appropriate box.
5. In the 'Patient Information' section, fill out the 'Member Name,' 'Member Number,' 'Patient Name,' 'Group Number (if applicable),' and the 'Patient Date of Birth' in their respective fields.
6. For 'Service Description,' provide the necessary 'Diagnosis Codes' and list them clearly in the designated fields, ensuring that they accurately reflect the patient’s diagnosis.
7. List the 'CPT/HCPCS' codes that correspond to the services requested in the form provided area.
8. Use the 'Comments/Notes Describing the Service' section to provide any additional information that may support your request. Clearly state the reasons for the services being requested.
9. Include any 'Additional Information' that may clarify the request alongside the form. This can include test results, current conditions, pertinent history, and progress notes. Remember to fax these documents along with the completed form.
10. Review all entered information for completeness and accuracy. Once validated, save your changes, and prepare to download, print, or share the form as needed.

Complete your Prior Authorization Form online today to ensure timely processing of your request.