Get Washington Prior Authorization Fax Request Form

Filling out the Washington Prior Authorization Fax Request Form online is an essential step in securing necessary medical services efficiently. This guide will provide you with a clear, step-by-step approach to understanding and completing the form correctly.

Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to obtain the form and access it for editing.
2. Begin by filling out the date at the top of the form. This helps track when the request is submitted.
3. Provide the contact person's name, phone number, and fax number in the specified fields to ensure proper communication.
4. Indicate whether the fax line is HIPAA secure by marking the appropriate box.
5. Enter the requesting provider's name and their TIN/NPI in the designated spaces for identification.
6. Move to the member information section. Fill in the member's name, ID, date of birth, and answer questions about their pregnancy status, other insurance, and any related incidents.
7. Select the type of request by marking the appropriate checkboxes for routine, expedited, inpatient, outpatient, or home services.
8. Input the servicing provider and facility information, including name, TIN/NPI, address, and network status (in-network or out-of-network).
9. Complete the clinical information section by detailing diagnoses, ICD-9 codes, required CPT/HCPCS codes, and any related service information.
10. Review all entries to ensure all fields are completed accurately. This submission should include any relevant clinical data to support your request.
11. Once finished, save the changes, and you have the option to download, print, or share the form as needed.

Start your document submission process online today.