Follow the steps to complete the form online:

1. Press the ‘Get Form’ button to access the Inpatient Authorization Request form and open it in your preferred editor.
2. In the member section, fill in the required details: WellCare ID, last name, first name, middle initial, Medicare/Medicaid number, phone number, and date of birth.
3. Move to the requesting provider section. Enter the WellCare ID number, last name, first name, street address, phone number, provider type or specialty, NPI number, tax ID, city, state, and zip code.
4. Next, provide the treating provider's information, including their provider ID, last name, first name, address, phone number, specialty, city, state, fax number, and zip code.
5. In the facility section, check whether it is a planned admission or emergency notification, and fill out the facility name, street address, medical record number, NPI number, phone number, city, state, fax number, and zip code.
6. In the service requested section, specify the planned date of service and the duration, if applicable. Include the primary ICD-10 code and primary CPT-4 code or the requested length of stay.
7. Add detailed descriptions of the services requested and include any additional procedure codes in the clinical summary section.
8. Finally, review all information for accuracy, and then save your changes. You may download, print, or share the completed form as needed.

Take action now by filling out your Inpatient Authorization Request online for a streamlined submission.