General Authorization Request Form FAX REQUEST TO WVP: (503) 5817422 Standard Review Expedited Review: If standard timeframe could seriously jeopardize the life or health of the enrollee or the enrollees.
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How to fill out the General Authorization Request Form - ATRIO Health Plans online
Filling out the General Authorization Request Form is a crucial step in obtaining necessary medical authorizations. This guide will provide you with a clear, step-by-step approach to ensure that you complete the form accurately and efficiently.
Follow the steps to successfully complete your form online.
- Click ‘Get Form’ button to access the General Authorization Request Form and open it in your chosen editor.
- Begin with the section for the date, entering the current date at the top of the form. This is essential for tracking your request.
- In the Member Information section, fill in the member's name, ID number, and birth date. These details are required and must be accurate.
- Proceed to the Referring Physician Information section by entering the name and phone number of the referring physician. Also, provide the physician's fax number for any necessary correspondence.
- Next, in the Referral Information section, input the name of the provider or facility that will be involved in the care of the member.
- Fill out the Procedure/Item Request Information section by detailing the CPT/HCPC codes, descriptions, quantities, start dates, and end dates for the requested services.
- Indicate if the request is for outpatient or inpatient services. For inpatient requests, specify the length of stay required.
- Attach any necessary chart notes and write any other important information in the designated area provided on the form.
- Finally, ensure that the referring physician signs the form. This signature is mandatory for the request to be valid.
Complete your General Authorization Request Form online today for efficient processing.
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