Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to access the Pre Service Review Request For Authorization Form and open it in your selected editor.
2. In the provider information section, fill in the provider's name, date, phone number, fax number, tax ID, and office contact’s name and phone number. Make sure you provide complete and accurate contact details.
3. If services will be provided by another provider or vendor, list their full name, address, and phone number. If requesting out-of-network services, include a letter of medical necessity.
4. In the member/patient information section, enter the member's name, member number, and date of birth (DOB) in mm/dd/yy format.
5. Provide the treatment information including dates of service or admit date. If multiple visits are required, specify the number of visits and the date range.
6. Select the place of service (inpatient, outpatient, office, or patient’s home) by checking the appropriate box.
7. Fill in the diagnosis and diagnosis code(s) (ICD-9) as well as the procedure and procedure code(s) (CPT-4 or HCPCS).
8. If applicable, attach documentation related to clinical trials including a letter of medical necessity signed by the physician, trial protocol, IRB number, and approving body.
9. In the hospital/facility section, provide the full name, address, and phone number of the hospital or facility, especially if it is out of state or not a participating facility.
10. Review all the information entered for accuracy and completeness. After confirming that all fields are filled and documentation attached, save your changes, and choose to download, print, or share the completed form as needed.

Start filling out your Pre Service Review Request For Authorization Form online today for efficient processing.