Get Ebcbs Fax Auth Formpdf

Filling out the EBCBS Fax Auth Formpdf online can be a straightforward process if you understand the required information and how to navigate the form. This guide provides step-by-step instructions to help you complete the authorization request efficiently.

Follow the steps to accurately complete your authorization request.

1. Press the 'Get Form' button to access and open the EBCBS Fax Auth Formpdf in your preferred document editor.
2. Begin with the member/subscriber information section. Fill in the ID number, last name, and first name of the member or subscriber. This ensures that the request is linked to the correct account.
3. Next, complete the patient information section by entering the patient's last name, first name, date of birth, and sex. Additionally, indicate the relationship of the patient to the member/subscriber by selecting from 'Self,' 'Spouse,' or 'Child.'
4. If applicable, specify whether the service is related to a motor vehicle accident or if there is any additional insurance. If there is other insurance, provide the insurance company's name and indicate if it is the primary insurance.
5. Select the authorization requested by checking the appropriate box for the service needed. Limit your selection to one service per fax form.
6. Provide the admission date, first date of service, number of visits requested, requested length of stay, and the authorization period requested. This detailed information aids in the authorization process.
7. Enter any relevant diagnoses in the designated areas, including primary and secondary diagnoses along with their ICD10 codes, as well as the procedure and CPT4 codes.
8. Fill in the facility and provider information, including the name, and then provide details about the ordering physician, including their name, provider number, contact information, and address.
9. Finally, enter the name of the person submitting the fax request and ensure all fields are filled accurately. Review all entries for completeness and accuracy.
10. After confirming the information, save your changes. You can then download, print, or share the completed form as needed.

Complete your documents online today to ensure a smooth authorization process.