Get Ssm Health Prior Authorization Form Home Health And Hospice Fax

This guide provides comprehensive instructions on how to complete the SSM Health Prior Authorization Form for Home Health and Hospice services online. By following these steps, users with varying levels of experience can ensure they accurately fill out the necessary information required for timely processing.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering the patient demographics. Fill in the patient's name, member ID, street address, city, date of birth, phone number, and state.
3. Next, provide the referring provider information. Include the provider's name, street address, city, state, provider number, zip code, phone number, fax number, and specialty.
4. In the section for referred to physician/facility/provider information, enter the details for the provider to whom the patient is being referred, including name, address, city, state, and specialty.
5. Indicate the request information by filling in the dates of service, the phone number, and fax number related to this request, the zip code, along with the ICD-9 codes and their descriptions, and CPT codes and descriptions.
6. Specify the number of visits requested and indicate any third-party liability details, such as whether the request is for workers' compensation, home health, or motor vehicle accident services.
7. Provide a brief description of the services requested and any additional information that may assist in processing the request.
8. Complete the 'form submitted by' section, including the submitter's name and phone number.
9. After filling out all sections, you can save changes, download, print, or share the completed form as necessary.

Complete your documentation online to ensure swift processing of the SSM Health Prior Authorization form.