Follow the steps to complete the La Care Authorization form online

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by entering your personal information in the 'Patient Information' section. This includes the member's name, date of birth, member ID or Social Security number, address, and phone number.
3. Indicate the urgency of the service by checking the appropriate box for 'Urgent' (within 72 hours), 'Routine' (within 5 calendar days), or 'Post Service' (within 30 calendar days).
4. In the 'Referral – Service Type Requested' section, select the type of service you are requesting by checking the corresponding box. You may provide the expected duration for durable medical equipment (DME).
5. Fill in the requesting provider's information, including the name, specialty, phone number, address, and fax number.
6. Similarly, enter the information for the provider who will perform or provide the requested service, ensuring accuracy in their name, specialty, phone number, address, and fax number.
7. In the 'Diagnosis / Procedure Information' section, include the relevant ICD-9 codes and descriptions, CPT codes and descriptions, and HCPCS codes and descriptions.
8. Provide the clinical indications for the request by detailing any pertinent past medical treatments, physical findings, and attaching all relevant medical records and test results.
9. The requesting provider should print their name, sign, and date the form. If this request is for services at an out-of-network facility, include the rationale in the designated area.
10. Once the form is complete, review all information for accuracy. Then, save your changes, download the completed form, and print or share it as needed.

Start submitting your documents online today to ensure a timely review process.