Get Ped-i-care Out-of-state Authorization Request Form - Com-peds-pedicare Sites Medinfo Ufl

This guide will provide you with clear and comprehensive instructions on how to accurately complete the PED-I-CARE OUT-OF-STATE AUTHORIZATION REQUEST FORM. By following the steps outlined below, you can ensure that all necessary information is provided for your authorization request.

Follow the steps to successfully complete the authorization request form.

1. Press the ‘Get Form’ button to access the authorization request form. Make sure to open it in your preferred document editor.
2. Begin with Section 1: Member Info and Type of Request. Fill in the member's name, date of birth, member ID number, age, and gender. Indicate the relevant program (Title XIX or Title XXI) and choose the request type: Standard, STAT, or Retro.
3. For diagnosis codes, enter the relevant codes to reflect the member's medical condition. Include the name and contact number of the referring provider along with the name of the primary care provider, if different.
4. In the requested dates of service, provide the start and end dates for treatment.
5. Move to Section 2: Clinical Information. Attach clinical documentation as necessary. Summarize attempts to find care within Florida and outline the out-of-state treatment plan along with the expected number of follow-up visits.
6. Describe the strategy for transitioning the member's treatment back to a Florida provider after the out-of-state services.
7. Proceed to Section 3: Information for Out-of-State Provider(s). List the involved facilities or specialists. For each provider, include details such as facility name, specialty, procedure codes, contact information, and their acceptance of out-of-state Medicaid.
8. Complete any additional comments or information regarding the authorization request if necessary.
9. Once all fields are filled out accurately, review the document for completeness. Finally, save the changes, and you can choose to download, print, or share the form as required.

Complete your authorization request form online today for a smoother process.