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Filling out the Wvchealth referral/prior authorization request form online can streamline the process and ensure all necessary information is collected efficiently. This guide provides clear, step-by-step instructions for completing each section of the form, making it accessible for all users.

Follow the steps to complete the form online effectively.

1. Press the ‘Get Form’ button to access the referral/prior authorization request form and open it in your online editor.
2. Start by entering the member ID and member name in the appropriate fields. Ensure that the information is accurate to facilitate the request.
3. Input the member's phone number and date of birth, which helps in verifying their identity and eligibility.
4. Provide the referring provider's name and the office contact details including fax and phone numbers.
5. Specify the service date range by filling in the start and end dates carefully.
6. Indicate the primary ICD (10) code and detail the number of visits or units needed.
7. Select whether the referral is in-network or out-of-network, and include any necessary justification for an out-of-network request.
8. Choose the type of request: consult only, allow surgery, sub referral authority, or consult and treat, along with any other specific treatment requests.
9. If applicable, attach clinical notes and documentation demonstrating medical necessity for the requested service.
10. Complete the facility/vendor information, specifying whether the request is for outpatient or inpatient services.
11. Provide the requested service (CPT) information and include any additional medication requests that require prior authorization.
12. Fill in details for any durable medical equipment needed, including whether it is for rental or purchase.
13. Before submitting, review all data entered for accuracy and completeness.
14. Finally, save the changes, download, print, or share the completed form as required.

Complete your Wvchealth referral/prior authorization request form online today and ensure a smooth process.