Get Form La Paf 0658

Filling out the Form La Paf 0658 is a crucial step in requesting authorization for outpatient services. This guide provides clear, step-by-step instructions to help users complete the form accurately online.

Follow the steps to successfully complete the Form La Paf 0658 online.

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. Begin by entering the date of birth in the specified format (MMDDYYYY) along with the member ID or Medicaid ID. Ensure that all fields marked with an asterisk (*) are completed as they are required.
3. In the requesting provider information section, input the requesting NPI and TIN, along with the contact name and provider name. Add the phone number for any necessary follow-ups.
4. In the authorization request section, enter the primary procedure code, along with additional procedure codes if applicable. Include the diagnosis code and the total number of units, visits, or days requested.
5. Select the outpatient service type by entering the service type number in the designated boxes. Ensure you include all necessary codes and modifiers for accurate processing.
6. Once all sections have been completed and verified, save any changes you made. You may then download, print, or share the completed form as needed.

Complete your Form La Paf 0658 online to ensure timely processing of your authorization request.