Get Authorization Request

Completing the Authorization Request form online is a straightforward process that ensures your requests are processed efficiently. This guide provides clear, step-by-step instructions to help you navigate each section of the form with ease.

Follow the steps to efficiently complete your Authorization Request.

1. Click 'Get Form' button to access the Authorization Request form and open it in the provided editor.
2. Enter the date of your request in the designated field. This serves as a timestamp for your request processing.
3. Indicate whether your request is standard or urgent by selecting the appropriate option. Standard requests take up to 10 business days, while urgent requests may be completed within 24-48 hours.
4. Complete the 'Request Sent By' section with your name and contact number to ensure communication regarding your request.
5. Fill in the member's name (first and last) along with their ID number to identify the individual for whom the authorization is being requested.
6. Select the plan under which the request is being made, such as Direct, PACE, or FIDA.
7. Provide the referring provider's information, including their contact number, to facilitate any necessary follow-up.
8. Fill out the 'Referred to Provider' section by selecting the type of provider—In-Network, Out of Network, or Specialist—and include their contact number.
9. Clearly state the reason for the request. Be as specific as possible and attach any additional clinical information as necessary.
10. Indicate the type of service requested and provide the expected dates of service or number of visits.
11. Specify the place of service and ensure to include the diagnosis/ICD9 code and procedure/CPT code if applicable.
12. If applicable, explain the reason for the out-of-network request.
13. Attach any additional clinical information that supports your request.
14. Once all fields are completed, review the information for accuracy. You can then save your changes, download the form, print it, or share it as required.

Complete your Authorization Request online today for timely processing of your requests.