Get Authorization Request Lasalle Inland Empire Form 11-16-2012doc - Portal Nmm

Filling out the Authorization Request LASALLE INLAND EMPIRE Form is an essential process for seeking medical referrals and ensuring effective treatment. This guide will provide you with step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to successfully complete the Authorization Request form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin filling in the 'Referral Request Date' by entering the appropriate date in the provided field.
3. Indicate the urgency of the request by circling one of the options: Routine, Urgent, or Retro.
4. Complete the 'Patient Information' section with the patient's full name, date of birth, age, sex, and contact details.
5. Provide the patient's health plan information, member ID number, and member effective date.
6. Fill in the referring provider's name, their phone number, and fax number.
7. Identify the specialty to which the patient is referred and enter the name of the office contact at the specialty clinic.
8. Indicate the services to be provided by selecting the appropriate option such as Office, Inpatient Stay, or Outpatient Hospital.
9. For 'Direct Referrals Only', check the box that corresponds to the requested facility.
10. Provide the necessary diagnosis and enter the relevant ICD-9 codes.
11. List the requested services or treatments, ensuring to include a detailed description and corresponding CPT code.
12. Complete any fields regarding clinical problems, pertinent clinical history, treatments tried or failed, and rationale for the referral.
13. Have the referring physician sign and date the form in the designated area.
14. Once all fields are filled out, review for completeness and legibility to ensure no required information is missing.
15. Finally, save your changes, and choose to download, print, or share the completed form as necessary.

Start filling out your documents online to ensure efficient processing.