Get Existing Authorization Complete And Fax To: 18778089368 Units Standard Request Determination Within

This guide provides detailed instructions on how to complete the Existing Authorization Complete And Fax To: 18778089368 Units Standard Request Determination Within form accurately and efficiently. By following these steps, users can ensure that their requests for additional units are submitted correctly.

Follow the steps to successfully complete the authorization form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member information. Fill in the member ID, date of birth, last name, and first name in the designated fields. Ensure all fields marked with an asterisk (*) are completed, as these are required.
3. Provide the requesting provider information. Enter the requesting NPI (National Provider Identifier), TIN (Tax Identification Number), provider contact name, provider name, phone, and fax. Again, ensure that all required fields are filled.
4. If applicable, indicate if the servicing provider is the same as the requesting provider. If not, fill in the servicing provider information, including the servicing NPI, TIN, provider contact name, and facility name along with phone details.
5. Input the authorization request details, including ICD-9 or ICD-10 codes. Fill in the primary procedure code, total units/visits/days, additional procedure codes, and the start or admission date. Ensure to include modification information if necessary.
6. Select the outpatient service type by entering the corresponding service type numbers in the provided boxes. Make sure to refer to the provided examples to choose the correct options.
7. Complete any remaining fields while ensuring all required information is provided. Incomplete forms will be rejected.
8. Once all sections are completed, review the form for accuracy and save your changes. You can then download, print, or share the completed form for submission.

Take action now by completing your authorization form online!