Follow the steps to complete your Fidelis Pt Auth Form online

1. Press the ‘Get Form’ button to obtain the Fidelis Pt Auth Form and access it in the online editor.
2. Enter the Fidelis Care member name in the format Last, First, M.I., followed by the member ID number and the date of birth in the specified format.
3. Input the servicing provider's name, title, and tax ID number. Don't forget to include the provider's address along with the city, state, and zip code.
4. Fill in the servicing provider's NPI number and their contact information, including the phone and fax numbers.
5. Document the IPA affiliation if applicable, and proceed to enter the relevant ICD-10 diagnosis codes along with their descriptions.
6. Continue by entering the CPT/HCPCS codes and descriptions for the home health care services being requested, along with the number of visits requested.
7. Indicate whether all prior visits have been used by selecting 'YES' or 'NO' and mention how many visits remain if applicable. Provide the existing authorization number if known.
8. Detail any previous treatment for the diagnosis along with the last treatment date and the quantity of services requested.
9. Specify the length of service, necessary supplies, and any additional services needed, circling each that applies, such as Physical Therapy (PT), Occupational Therapy (OT), or others.
10. Review all entered information to ensure accuracy and completeness before proceeding to save changes, download, print, or share the form as required.

Complete your Fidelis Pt Auth Form online to facilitate your request for home health care services.