Get Prior Authorization Form - Harbor Health Plan

The Prior Authorization Form for Harbor Health Plan is essential for ensuring that services are authorized before they are provided. This guide will provide you with detailed, step-by-step instructions on how to accurately complete this form online.

Follow the steps to complete the form effectively.

1. Click the ‘Get Form’ button to access the Prior Authorization Form and open it in the editor.
2. Fill in the requesting provider section. Include the date and circle whether the request is routine or urgent. Ensure to provide the provider's name and specialty.
3. Complete the member information section by entering the member's name (last, first, middle initial), date of birth, contact name, phone number, ID number, and fax number.
4. Provide details for the requested provider. Include their name, specialty (if applicable), address, phone number, and fax number.
5. In the requested services section, enter the diagnosis code(s), clearly stating whether the service is inpatient or outpatient. Also, include the date of service.
6. List the procedure code(s) and the number of services required. Be thorough in this section to ensure accurate processing of your request.
7. Attach any relevant clinical information that supports the service request to ensure proper review.
8. Once all fields are completed, save your changes. You may then download, print, or share the form as required.

Begin filling out the Prior Authorization Form online today to ensure timely service requests.