Get Pre-authorization Form - First Continental Life

Completing the Pre-authorization Form for First Continental Life is an essential step in ensuring that your claims are processed efficiently. This guide will provide clear and concise instructions to help you fill out the form accurately and with confidence.

Follow the steps to successfully complete the Pre-authorization Form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. In Section 1, enter today’s date and the procedure date. Indicate the number of visits or days requested. Fill in your name and contact information, including your phone number and fax number.
3. Proceed to Section 2 and provide the member or patient information. Fill in the full name of the patient, their date of birth, and their identification number.
4. In Section 3, input the name of the requesting provider and their provider number. Ensure accurate information to facilitate processing.
5. Move to Section 4 to enter the servicing provider's name and provider number. Additionally, include the diagnosis and the relevant ICD codes.
6. Section 5 requires you to write in the requested procedure codes and CPT codes associated with the services requested.
7. In Section 6, provide any clinical information relevant to the request. This may include notes or treatment history that supports the pre-authorization.
8. Review the instructions in Section 7. After completing the form, fax it to StarDent at the provided number. Note the date faxed.
9. If you have any questions, reach out to the provided customer service number for assistance.
10. Finally, ensure that you save any changes you have made. You can then download, print, or share the completed form as needed.

Start completing your Pre-authorization Form online today for a smoother claims process.