Get Authorization Request Form - Positive Healthcare

Filling out the Authorization Request Form - Positive Healthcare is a crucial step for obtaining necessary medical services and specialist visits. This guide provides clear and supportive instructions to help you accurately complete the form.

Follow the steps to efficiently complete your authorization request.

1. Click ‘Get Form’ button to access the Authorization Request Form and open it in your chosen online editor.
2. Begin by entering the date of your request at the top of the form. This is essential for processing timelines.
3. Indicate whether the request is urgent by checking the appropriate box, if applicable.
4. In the Patient Information section, select the relevant plan option: Positive Healthcare Partners or Positive Healthcare California, ensuring you choose the correct one based on your coverage.
5. Complete the patient's name, member ID number, birth date, primary care provider's name, and contact details. Accurate details are vital for processing your request.
6. Fill out the Referring Provider Information with the primary care provider's name and contact details.
7. Provide the indication for referral, including diagnosis codes, CPT codes, and any clinical conditions or lab data that may support the approval of this request.
8. Specify the requested consultation or service clearly to ensure the review team understands the need.
9. Lastly, enter the requested provider or facility name, along with their phone and fax numbers to facilitate communication.
10. Once all fields are complete, review the form for accuracy. Save your changes and then download, print, or share the completed form as necessary. Be sure to fax it to Utilization Management at (323) 337-9143.

Start filling out your Authorization Request Form online today to streamline your healthcare services.