Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling out the member information, including the member's last name, first name, and member ID number. Make sure to include the date of birth and today's date.
3. Provide details about the admission or procedure, including the date and diagnosis codes. Make sure to fill out the discharge date and diagnosis description thoroughly.
4. Input the CPT codes along with a detailed procedure description. Specify whether the procedure pertains to the left, right, or bilateral side.
5. If applicable, complete the newborn information section for obstetric admits. Include EGA, weight, Apgar score, and the date for the first Hepatitis B vaccine.
6. Fill out the requesting provider information, including their full name, NPI or tax ID number, specialty, phone number, and fax number.
7. Complete the facility information with the hospital or facility's full name, phone number, NPI or tax ID number, and fax number.
8. Provide your own information as the person completing the form, including your name, phone number (with extension), and fax number.
9. Attach any supportive clinical documentation needed to substantiate the request, such as health assessments, office notes, laboratory and imaging results, and therapy reports.
10. Review all entries for accuracy and completeness. Once finalized, you can save the changes, download the document, print it, or share it as required.

Complete your Authorization Request For Inpatient And Outpatient Services form online today for a smoother submission process.