Get Prior Authorization Fax Request Form - Uhccommunityplan.com

Filling out the Prior Authorization Fax Request Form is an essential step for ensuring timely access to necessary healthcare services. This guide provides clear, step-by-step instructions to help users complete the form accurately, facilitating smooth processing of authorization requests.

Follow the steps to effectively complete the form

1. Use the ‘Get Form’ button to access the form and open it for editing.
2. Enter the date, your contact information, and ensure to identify whether the fax line is HIPAA secure by checking the appropriate box.
3. Input the requesting provider details, including their name and TIN/NPI number.
4. In the member information section, provide the member's name, ID number, date of birth, and respond to questions about their pregnancy status, other insurance, and any relevant accidents.
5. Select the type of request by checking whether it is routine, expedited/urgent, inpatient, outpatient, or home.
6. Fill in servicing provider and facility details, including names, TIN/NPI numbers, addresses, and service dates, while also indicating if they are in-network or out-of-network.
7. Provide clinical information including diagnoses, relevant ICD-9 codes, CPT/HCPCS codes, number of visits, and frequency.
8. Complete any additional fields regarding previous services and the costs, ensuring all necessary clinical data is attached to support your request.
9. Review all entries for accuracy and completeness before proceeding.
10. Save your changes, and choose to download, print, or share the completed form as needed.

Begin completing your forms online today to support timely healthcare access.