Get Wellcare Outpatient Authorization Request Form

Completing the Wellcare Outpatient Authorization Request Form online is a straightforward process that ensures members receive timely and appropriate care. This guide will help you navigate each section of the form with ease and clarity.

Follow the steps to fill out the Wellcare Outpatient Authorization Request Form online:

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the member's details including the Member Plan ID, Today's Date, Member's Last Name, First Name, Phone Number, and Date of Birth.
3. In the Requesting Provider section, input the Provider ID, Type, Last Name, First Name, Phone Number, Specialty, and Fax Number.
4. If applicable, fill out the Treating Provider section or check the box to let the plan assign the provider. Input the Provider ID, Specialty, Last Name, First Name, Address, City, Phone Number, State, and ZIP.
5. Next, complete the Facility section by selecting the type, adding the Medical Record Number, or checking the box to have the plan assign the facility. Include Facility ID, Name, Address, City, Phone Number, Fax Number, State, and ZIP if necessary.
6. In the Service Requested section, specify the Planned Date of Service, Primary ICD-9 Code, and CPT-4/HCPC Code. Also, provide a description of the services or procedures and the visits/frequency.
7. Complete the Pertinent Clinical Summary, attaching any required supporting clinical records, if necessary.
8. Finally, review the completed form for accuracy. Save your changes, download, print, or share the form as needed.

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