Get Re: New Authorization Request Form - Managed Care Systems

Completing the New Authorization Request Form is essential for facilitating approvals of necessary medical services within Managed Care Systems. This guide provides a clear and supportive framework to ensure you fill out the form accurately and efficiently.

Follow the steps to complete the authorization request form effectively.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering the patient's identification information. Fill in the last name, first name, address, city, state, and zip code. If the address has changed, indicate this by selecting ‘yes’ or ‘no’. Include home and work phone numbers, relation to subscriber if applicable, date of birth, and sex.
3. Complete the subscriber identification section. If the subscriber is not the patient, provide their last name, first name, middle initial, subscriber ID number, and any other relevant coverage information.
4. Outline the reason for referral. Include the date of request, symptoms, patient diagnosis, and the appropriate ICD-9 code, if applicable. You can also provide any diagnostic tests conducted prior to submission.
5. For each requested service or procedure, list the provider/specialty/facility name, provider phone number, requested service or procedure, and corresponding procedure code. Repeat this process for up to six services as needed.
6. Indicate the expected date of service or procedure. Mark whether the request is for office, outpatient, inpatient, or ambulatory surgical center services.
7. Review all entries for accuracy. Once completed, save any changes to the form. You can download, print, or share the form as necessary.

Act now to complete and submit your authorization request form online for timely processing.