Get Attn: Um Department-referral Coordinator Phone: (206) 326-2453 Option 1; Fax: (206) 621-4026

Filling out the Attn: UM Department-Referral Coordinator form online is essential for processing prior authorization requests efficiently. This guide provides clear steps to assist you in completing the form accurately and effectively.

Follow the steps to fill out the form with ease.

1. Press the ‘Get Form’ button to access the document and display it in your editor.
2. Enter the current date in the designated field at the top of the form, ensuring it is formatted correctly.
3. Fill in the patient's name in the 'Patient Name' section, using full legal names for accuracy.
4. Provide the patient's date of birth (DOB) in the appropriate field, ensuring it is in MM/DD/YYYY format.
5. Input the patient's Insurance ID number to verify coverage.
6. List the patient’s primary care physician (PCP) to ensure coordinated care.
7. Select the type of referral or service requested by checking the relevant boxes under 'REFERRAL/SERVICES TYPE REQUESTED'.
8. For each service selected, indicate if it is inpatient or outpatient and include specific procedures or treatments as per the guidelines.
9. Complete the PROCEEDURE INFORMATION section by inputting the ICD-10 code and description, CPT/HCPCS codes, and the number of visits requested.
10. Fill out the REFERRING PHYSICIAN INFORMATION and the REFERRING FACILITY/PHYSICIAN INFORMATION sections completely to ensure correct processing.
11. Attach any clinical notes and supporting documentation required for medical necessity review before submission.
12. Review all entered information for accuracy and completeness before proceeding to submit the form.
13. Once you have completed the form, you can choose to save changes, download, print, or share the form as per your needs.

Start filling out your form online today for prompt processing!