Get Service Authorization Form (css01) - Colorado Access

This guide provides step-by-step instructions for filling out the Service Authorization Form (CSS01) for Colorado Access online. Navigating the form accurately ensures that you provide all necessary information for service authorization.

Follow the steps to complete the Service Authorization Form successfully.

1. Click the ‘Get Form’ button to access and open the Service Authorization Form (CSS01) in the online editor.
2. Begin filling out the top section of the form. Include today's date, the requesting provider's name, and the member's name. Also, provide the name of the person completing the form. Ensure that the State ID, date of birth (DOB), phone number, fax number, and email address are accurately filled in.
3. In the clinical history section, indicate if the referral is a result of an abnormal EPSDT screen or a comprehensive well-child visit by checking 'Yes' or 'No.' Specify if the member has a case manager and include their name and phone number if applicable.
4. Address the member's participation in specific programs such as Prenatal Plus, Nurse Family Partnership, or WIC. Circle the relevant programs if applicable.
5. If the member has other insurance, check 'Yes' and specify if it's Medicare or another type of insurance. Provide the necessary details.
6. In the section for diagnosis codes, input up to two ICD-9 codes as applicable to the member's condition.
7. Check the services requested by selecting from the options provided (e.g., OB Services, therapies). If multiple service types need authorization, note that you will need to use form CSS02.
8. Fill in any additional necessary information regarding requested visits, procedure codes, and whether the service is outpatient or inpatient. Indicate the number of visits and frequency as applicable.
9. Provide details about the providers involved, including full names, specialties, phone numbers, and fax numbers.
10. Review the entire form for completeness and accuracy. Once all fields are filled, you can save changes, download, print, or share the completed form as necessary.

Complete your Service Authorization Form online to ensure a smooth and efficient authorization process.