Follow the steps to complete the MA 97 Form online effectively.

1. Press the ‘Get Form’ button to access the MA 97 Form, then open it in your preferred editing tool.
2. Identify the type of request you are making in Items 1 & 2. Check one box only for either prior authorization or 1150 waiver. Ensure to fill out a separate form if both requests are needed.
3. Complete Patient Information (Items 3–6) by entering the recipient number, patient's full name (last, first, middle initial), birthdate in MMDDCCYY format, and optionally, check the gender box.
4. Input Provider/Prescriber Information (Items 7–11) with the provider's complete name, 13-digit Provider ID, Optional reference number, and complete details for payment recipients if applicable.
5. If applicable, fill out the Referring Practitioner/Prescriber section (Items 12–15), including their name, license number, telephone, and address.
6. Enter the Primary Diagnosis (Item 16) and corresponding ICD-9-CM Diagnosis Code (Item 17). Complete the Secondary Diagnosis section (Items 18-19) if necessary.
7. For Requested Services (Items 20A-29), describe the services needed and enter the procedure codes, quantities, and financial specifics as indicated.
8. Provide additional information under Item 27 about alternatives previously tried, and check the recipient's current residential status in Item 28.
9. In Item 29, include a narrative description of symptoms or medical justification for your request before submitting any additional attachments in Item 30.
10. Sign the form (Items 33-36) both by the patient or authorized representative and by the practitioner, ensuring dates and professional details are filled out.
11. Once completed, save your changes, and proceed to download, print, or share the MA 97 Form online.

Start completing your MA 97 Form online today for swift authorization of outpatient services.