Get 800 860 8720

This guide provides clear and supportive instructions on completing the 800 860 8720 form online. By following these steps, you can efficiently fill out the required information for your authorization request.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to access the form and open it within your document management system.
2. Begin by entering the Fidelis Care member's name in the format of last name, first name, and middle initial.
3. Fill in the Fidelis Care member ID number in the designated field.
4. Provide the CPT/procedure code(s) along with a brief description of the services needed.
5. Enter the ICD-10 diagnosis code(s) relevant to the request.
6. Record the date of birth of the patient in the mm/dd/yyyy format.
7. If applicable, check the appropriate boxes for Medicare, No-Fault, or Workers' Compensation.
8. If there's a date of injury, enter it in mm/dd/yyyy format; if there is a date of procedure, do so as well.
9. Complete the provider's name and include their phone number with area code.
10. Input the provider's tax ID or NPI number and fax number.
11. If applicable, specify the IPA affiliation.
12. Indicate whether the request is for inpatient or outpatient services.
13. Check the appropriate option if the request is urgent/emergent or for pre-service.
14. Add any additional information that might support the request.
15. Circle all included clinical information that you are submitting with the form, such as history and physical, treatment history, or lab results.
16. Review the entire form to ensure all fields are filled out completely and legibly before submission.
17. Submit the completed form by faxing it to 800-860-8720. You will receive a determination within the regulatory timeframe.

Complete your documents online to ensure swift processing of your request.