Get All Prior Authorization Requests Must Either Be Faxed On This Template Or Be Submitted Through The

Filling out the All Prior Authorization Request form accurately is essential to ensure timely processing of your request. This guide provides step-by-step instructions to assist users in completing the form correctly, whether submitting via fax or online.

Follow the steps to complete the authorization request form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date requested, your name, and phone number in the designated fields. These are critical for tracking your request.
3. Fill in the case file number and the claimant's details, including their name and date of birth. Accurate information here is vital for processing.
4. Document the date of injury to provide context for your request.
5. Provide the provider's name, Xerox Provider Number, and their tax ID. This information is necessary to identify the service provider.
6. Indicate whether you are in the process of enrolling by selecting 'Yes' or 'No'.
7. If applicable, enter up to five procedure (CPT/HCPCS) codes along with the relevant service dates and other associated details such as modifier, number of units, frequency, duration, and total units requested.
8. Specify the body part to be treated as well as the treatment plan information, including whether the requested therapy is related to post-operative treatment.
9. Calculate Total Units/Days Requested for each procedure code using the formula: # of Units Requested (per procedure) x Frequency Requested x Duration Requested.
10. Add any additional comments or notes that may help clarify the request.
11. Ensure to attach supporting medical documentation and prescriptions from the attending physician, including the case file number on every page faxed.
12. Once completed, review the entire form for accuracy, then save any changes, download, print, or share the form as needed.

Complete your prior authorization request online today for efficient processing!