Follow the steps to complete your authorization request form.

1. Click ‘Get Form’ button to access the document and open it in your editor.
2. Fill in the date of your request in the format ____/____/____. This is important to establish when the request is being made.
3. Provide your contact name and phone number. Make sure to include the extension if applicable, along with the fax number.
4. Enter the member ID number, the first and last name of the member, and their date of birth in the required format ____/____/____.
5. Indicate the requesting provider's first and last name. If the request is initiated by the primary care provider (PCP), be sure to check the corresponding box.
6. Select the applicable request type(s) for either out of network specialist referrals or other services. Complete any requested information accordingly.
7. Input the performing provider’s details, including their first and last name, specialty, NPI number, tax ID number, address, phone number, and fax number.
8. Choose the type of service by checking the relevant box, whether it be office, outpatient, inpatient, or another category.
9. Fill in the DME/Prosthetics/Orthotic supplies section if applicable, entering the supplier name, type of equipment, and HCPCS codes.
10. Complete the diagnosis and procedure description sections, including necessary codes.
11. If requesting an expedited review, be sure to check the appropriate box and provide any supporting information.
12. Review all completed sections for accuracy. Once satisfied, save your changes and proceed to download, print, or share the form as necessary.

Start completing your authorization request form online today for a smooth submission process.