Get Fax Completed Form For

Filling out the FAX completed form for prior authorization can seem daunting, but this guide provides clear, step-by-step instructions to help you complete the process online. Accuracy in the information you provide is essential for a timely approval.

Follow the steps to fill out the FAX completed form for prior authorization accurately

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the patient’s information in the designated fields, starting with their last name, first name, and middle initial. Ensure accuracy as this information is critical for identification.
3. Enter the patient's Medicaid identification number into the appropriate field to verify their eligibility.
4. Provide the patient’s date of birth in the format M/D/YY to ensure precise age identification.
5. Input the dispensing provider's name, ensuring it matches with your records.
6. Include the provider's phone number and fax number, which are crucial for communications regarding the authorization.
7. List the provider's taxonomy number and National Provider Identifier (NPI) for identification in the healthcare system.
8. Specify the dates covered by the request, using the format Mo/Day/Year for both the start and end date.
9. In the section for requested services, enter the appropriate ICD-10 codes to identify the medical conditions being addressed.
10. Provide additional details in the reasons for request section, ensuring all necessary information is included. You may use a separate sheet if needed.
11. Fill in the lines for procedure supplies, drugs to be provided, codes (HCPCS, CPT, CDT), units of service, and the amount requested.
12. Leave the sections for authorized units and amounts blank, as these will be filled by the reviewing authority.
13. Sign and date the form as the requesting provider to certify that all information provided is accurate.
14. Review the completed form thoroughly to ensure all fields are filled out completely and accurately before submission.
15. Save your changes, and then download, print, or share the form as required.

Complete your documents online today for a streamlined filing process.