Get Outpatient Authorization Request And Physician Request For

Filling out the outpatient authorization request and physician request form online is an essential step in ensuring necessary medical services, transportation, lodging, and meals are obtained. This guide provides clear, step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to access the authorization request form and open it in your digital editor.
2. Begin with the member information section. Input the member's 'ʻOhana ID Number,' 'Name,' 'Date of Birth,' 'Address,' and 'Phone Number' accurately. This information is critical in identifying the member.
3. Move to the service/procedure/treatment information section. Fill in the 'Planned Date of Service,' 'ICD Diagnosis Codes,' 'Place of Service,' and 'CPT/HCPCS Code(s).' Ensure all codes are correct to avoid processing delays.
4. Provide details in the provider information section. Here, include both the requesting/referring provider and treating provider’s names, provider IDs, phone numbers, and addresses. This section ensures clarity on the healthcare professionals involved.
5. If applicable, complete the out-of-state/out-of-network section that may require additional details for travel and lodging requests. Specify if lodging or meals are needed, the type of transportation, and provide appointment details.
6. In the additional information section, include any relevant clinical summaries or reasons for referral to out-of-state providers. Attach any supporting documentation to facilitate the authorization process.
7. Review all information entered for accuracy and completeness. Make corrections as necessary before final submission.
8. Once everything is correctly filled out, save your changes, and choose to download, print, or share the completed form as required. Ensure to fax the completed form to the provided number.

Complete your outpatient authorization request and physician request form online for a smoother healthcare experience.