Get **chart Notes Required** - Healthplans Providence

Filling out the **Chart Notes Required** form for Healthplans Providence is essential for ensuring proper authorization requests for medical services. This guide offers a clear and structured approach to assist users in completing the form accurately and efficiently.

Follow the steps to accurately complete the **Chart Notes Required** form online.

1. Press the ‘Get Form’ button to access the **Chart Notes Required** document and open it in your editor.
2. Begin by entering the member information. Fill in the last name, first name, member ID number, date of birth, and address.
3. Proceed to the provider information section. Input the primary care physician's name, requesting provider details including their TIN and NPI numbers, and the addresses where applicable.
4. Next, provide information about the servicing provider and facility. This includes entering their respective TINs, NPI numbers, and addresses.
5. For the request information, input the ICD-10 and CPT codes relevant to the services being requested. Specify the type of services required such as office visits, surgeries, or diagnostic tests.
6. Indicate the date span requested and any additional comments that may help clarify the request.
7. Complete the contact information section by providing your name, phone number, fax number, and the total number of pages being faxed, including the cover page.
8. If applicable, check the box for in-network benefits being requested and indicate if it is urgent by selecting the expediting option. Finally, review all entered information for accuracy.
9. Once completed, you can save the changes, download, print, or share the form as needed.

Now that you know how to fill out the form, proceed to complete your documents online.