Get Precertification Request For Authorization Of Facility - Medstarprovidernetwork

Filling out the Precertification Request For Authorization Of Facility form is an important step in securing authorization for facility-based services. This guide will provide a clear, step-by-step approach to help users complete the form efficiently and accurately.

Follow the steps to fill out the form online effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the 'Request From' section. Indicate whether the request is from a doctor's office or a hospital. Enter the requestor’s name, date, telephone number, and fax number.
3. In the 'Participating Provider Number' field, enter the number under which you bill claims along with the Tax ID.
4. Provide the patient's information, including the patient’s name, date of birth, ID number, and group number. Also, fill in the patient's address, city, state, and zip code.
5. Specify the date(s) of service or admit date(s) alongside the place of service by checking the appropriate box (Inpatient Facility, Office, Outpatient Facility, or Emergency Room Admit).
6. Fill in details for the admitting/treating physician. This includes their name, telephone number, and address.
7. Input the diagnosis code(s) (ICD-9) and procedure code(s) (CPT-4) as applicable.
8. Include the hospital/facility name, telephone number, and address associated with the request.
9. In the comments section, provide any additional notes or information that may assist with the authorization request.
10. Ensure to attach any relevant documentation such as progress notes, lab results, or consultation reports for review.
11. After reviewing all fields for accuracy, save your changes. You may then download, print, or share the completed form as needed.

Complete your Precertification Request online now for a smoother authorization process.