Get Outpatient Prior Authorization Fax Form

Filling out the Outpatient Prior Authorization Fax Form accurately is essential for ensuring timely processing of your request. This guide provides a detailed, step-by-step approach to assist you in completing the form effectively.

Follow the steps to accurately complete the form.

1. Click 'Get Form' button to obtain the form and open it in an editable format.
2. Begin by entering the member information, including the Member ID and Date of Birth (MMDDYYYY format), and the member's last name and first name in the designated fields marked with an asterisk.
3. In the requesting provider information section, input the Requesting NPI and Requesting TIN, both of which are mandatory fields. Additionally, provide the requesting provider's contact name, phone number, and fax number.
4. If the servicing provider is the same as the requesting provider, select the appropriate option. If not, enter the Servicing NPI and Servicing TIN along with the servicing provider's contact name, facility name, phone number, and fax number.
5. For the authorization request section, complete the ICD-9 and ICD-10 codes if applicable, alongside any additional procedure codes. Fill in the start or admission date and end or discharge date using MMDDYYYY format.
6. Specify the total units, visits, or days required and enter the primary procedure code (CPT/HCPCS). Include any modifiers or additional procedure codes as needed.
7. Indicate the outpatient service type by entering the corresponding service type number in the provided boxes.
8. Before submitting the form, ensure all fields marked with an asterisk are complete, and attach copies of any supporting clinical information, as incomplete forms may be rejected.
9. Once all information is accurately filled in, save changes to your document. You can download, print, or share the completed form as needed.

Complete your Outpatient Prior Authorization Fax Form online today to facilitate faster processing!