Follow the steps to fill out the Calviva Prior Authorization Form

1. Click the ‘Get Form’ button to obtain the Calviva Prior Authorization Form and open it in your preferred document editor.
2. Begin with the member information section. Fill in the member's name, including last name, first name, middle initial, and the date of birth in the format Mo/Day/Yr. Include the subscriber number and check the box for any other insurance policy if applicable.
3. Designate the type of request by checking the appropriate boxes, such as elective services or urgent requests. Provide details for urgent requests, including the explanation of clinical necessity.
4. In the service requested section, indicate the services you are requesting by checking the relevant boxes. Include the anticipated date of service.
5. Fill in the provider information for the requesting/ordering provider, including their first and last name, facility name, tax ID number, national provider identifier, and contact details.
6. Provide clinical information, including the required ICD-10 and CPT/HCPCS codes, and include any relevant clinical documentation that justifies the medical necessity of the request.
7. Sign and date the form, ensuring that any necessary agreements and acknowledgments are noted regarding patient awareness and care responsibilities.
8. After completing the form, you can save changes, download it, print a physical copy, or share it with relevant parties as needed.

Complete your Calviva Prior Authorization Form online now for a smoother request process.