Get Palm Harbor Authorization Form

Completing the Palm Harbor Authorization Form online is a straightforward process that ensures all necessary information is captured securely. This guide will walk you through each section of the form, providing step-by-step instructions to help you fill it out efficiently.

Follow the steps to complete the form online

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Enter the contact person's name, telephone number, and fax number in the designated fields. Ensure the information is accurate for any follow-up communication.
3. Provide a copy of the insurance card or include the member service phone number from the card in the relevant section.
4. Input the primary insured's information, including their legal name, member ID, address, city, state, and zip code. Also, include the insured's date of birth.
5. Indicate whether the member has other primary insurance by selecting 'Yes' or 'No'. If applicable, specify the type of primary insurance.
6. In the patient information section, enter the patient's legal name, address, member ID, city, state, date of birth, and zip code. Provide the type of plan they are enrolled in.
7. Add the primary care physician's (PCP) name and phone number. If there is a referring physician, include their name and phone number as well.
8. Fill out the treatment information section by providing the therapy office's name and address, the treating therapist's name, and verify the type of therapy needed.
9. List the ICD10 codes and corresponding diagnosis descriptions as required.
10. Indicate whether this is an initial referral or a continued referral. Provide the evaluation date and the surgery date if applicable.
11. After completing all sections, review the information for accuracy and completeness. Then you can save changes, download, print, or share the form as needed.

Complete the Palm Harbor Authorization Form online today to ensure timely processing of your request.