Get Ma 97 Form Pennsylvania

This guide provides clear, step-by-step instructions for completing the MA 97 Form for outpatient services authorization in Pennsylvania. Users will find detailed information tailored to assist them in accurately filling out the form online.

Follow the steps to complete the MA 97 Form with ease.

1. Click ‘Get Form’ button to acquire the MA 97 Form and open it for editing.
2. Begin by checking the box for either prior authorization or the 1150 waiver at the top of the form. This selection determines the type of request you are submitting.
3. In the patient information section, fill out items 3 to 6. Enter the recipient number, patient's name (last, first, middle initial), birthdate in mm/dd/yyyy format, and, if optional, check the box for sex.
4. For provider information, complete items 7 to 11, providing the provider’s name, provider ID, and other necessary references, only if applicable to your submission.
5. If applicable, fill in the referring practitioner's details in items 12 through 15, ensuring all required fields are completed accurately.
6. Enter the primary and secondary diagnoses in items 16 to 19, including the corresponding ICD codes where necessary, leaving blank where indicated.
7. In items 20A through 29, provide detailed information about the services requested, including a description, procedure codes, quantity, and justification narrative as per the form requirements.
8. Complete items 30 to 36, indicating the number of attachments if applicable, signing the form, and dating it appropriately. Ensure that both the patient or authorized representative and the practitioner provide their signatures.
9. Once all sections are complete, review the MA 97 Form for accuracy. Finally, save your changes, then download, print, or share the form as needed.

Take the next step towards efficient document management by filling out your forms online today.