Get Treatment Authorization Request For Services Outside Scvmc

This guide provides clear and detailed instructions for completing the Treatment Authorization Request for Services Outside SCVMC. Whether you are a healthcare provider or a user looking to manage this request, the following steps will help you navigate the online form with ease.

Follow the steps to complete the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Complete Section 1 by providing patient information including their first name, last name, date of birth, sex, phone number, and addresses, such as VMC medical record number and health plan ID. Ensure all fields are filled out accurately.
3. In Section 2, select the type of service required by checking the appropriate box for emergency, urgent, routine, or retrospective. Provide the details of the requested provider including their name, location, phone number, and fax number.
4. Much like Section 3, enter the specific services requested along with the appropriate CPT4 or HCPC codes. Include quantity, length of need, and provide medical justification for the request.
5. In Section 5, the requesting provider should print their name, sign the authorization request, and indicate the date on which they are signing.
6. Once all sections are completed, review the form for any errors, save your changes, and finalize by downloading, printing, or sharing the completed document as needed.

Start completing your Treatment Authorization Request online now for effective service management.