Get Prior Authorization Request Form

Filling out the Prior Authorization Request Form online can streamline your process and ensure that your requests are addressed promptly. This guide provides clear, step-by-step instructions for completing the form effectively to support your authorization needs.

Follow the steps to complete the Prior Authorization Request Form online.

1. Press the ‘Get Form’ button to access the Prior Authorization Request Form and open it in your preferred editor.
2. Begin by entering the ordering provider's information. Fill in the first name, last name, and contact information, including phone and fax details. Indicate if the ordering provider is a primary care provider (PCP) or a specialist.
3. Next, complete the patient information section. Provide the patient's first name, last name, middle initial, date of birth, and their CHPW member ID.
4. In the 'Service Provided By' section, enter the first and last name of the clinician or facility providing the service. Include the tax ID, specialty, and facility name, along with the contact phone and fax information.
5. Specify the clinical urgency of the request by indicating routine or urgent. Also, fill in the primary diagnosis code and description, along with the secondary code if applicable.
6. Detail the services being requested. Choose whether this is a new request or an extension, and provide CPT/HCPCS codes and descriptions for each service, including the number of visits and duration. If this is an extension, include the last date of service.
7. Lastly, review all information for completeness. Ensure that all required fields are filled out and that any necessary supporting clinical documentation is attached. After verifying, save changes, download, print, or share the form as needed.

Start completing your Prior Authorization Request Form online today.