Follow the steps to complete the form accurately and efficiently.

1. Press the ‘Get Form’ button to access the D04 Form 1144 and open it in an editable format.
2. Begin filling out the form by checking one of the service types requested. Only one type can be selected per form, such as EPSDT, outpatient facility, or transportation services.
3. Provide the Medicaid ID number of the patient and indicate if they have Medicare coverage by checking ‘Yes’ or ‘No’.
4. Enter the patient's full name, date of birth, and current location, selecting from the options provided (home, hospital, etc.). Include the patient’s mailing address, including street, city, and zip code.
5. In the physician section, detail the patient's diagnosis and include any justifications required, possibly attaching necessary documents.
6. Fill in the procedure code related to the requested services and provide a description in the supplier section, specifying the quantity, price, and any relevant serial numbers.
7. If requesting incontinence supplies, indicate the number of diapers, underpads, and gloves needed monthly, ensuring justification is attached if exceeding limits.
8. Both the physician and supplier (if applicable) must sign and print their names, along with the date, confirming that the requested services are medically necessary.
9. Once all fields are completed, save changes to your file, and consider your options to download, print, or share the form as necessary.

Complete the D04 Form 1144 online today to ensure timely medical authorization.