Get Ohio Uniform Authorization Form

The Ohio Uniform Authorization Form is an essential document used for authorizing mental health and substance use services. This guide provides clear, step-by-step instructions for filling out the form online, ensuring that users can complete it accurately and efficiently.

Follow the steps to fill out the Ohio Uniform Authorization Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the 'Date of Request' in the designated field. Make sure the date reflects the actual request date for services.
3. Select the 'Request Type' by checking either 'Initial' or 'Concurrent' as applicable.
4. Fill in the 'Member Name,' ensuring the full legal name is accurately recorded.
5. Provide the 'Date of Birth' (DOB) for the member in the specified format.
6. Enter the 'Member ID#' accurately, as this identification number is crucial for processing.
7. Input the 'Member Phone' number, making sure it is a valid and reachable number.
8. Indicate whether the service is 'Routine' or 'Expedited/Urgent' by selecting the appropriate option.
9. In the 'Provider Information' section, fill in the 'Billing Provider/Agency Name and Service Location' accurately.
10. Enter the 'Provider NPI/Provider Tax ID#' which is necessary for billing purposes.
11. Record the 'Contact Name' for the provider, ensuring it is the correct representative for communications.
12. Check the 'Provider Status' as either 'PAR' (Prior Authorized) or 'Non-PAR.'
13. Specify if the 'Member Court Ordered?' by selecting 'Yes' or 'No.'
14. Provide 'Phone#/Fax#' for the provider, as required.
15. In the 'Service Type Requested' section, choose the 'Service is for:' either 'Mental Health' or 'Substance Use.'
16. Enter the 'Service Code(s) requested,' ensuring the correct codes are utilized for each service.
17. Indicate the 'Units requested' for the services as per the member's needs.
18. Fill out the 'Requested Date of Service' field with the desired date this service is needed.
19. If applicable, provide details about 'Other Services/Out of Network Providers.'
20. Record the 'Primary Diagnosis (ICD-10)' and include any provisional diagnosis that may be necessary.
21. Document 'Clinical Symptoms & Social Barriers' that are relevant to this request.
22. Attach any required clinical documentation, such as Assessment Summary or Treatment Plan, to support the request.
23. Once all fields are completed and double-checked for accuracy, you may save changes, download, print, or share the form as needed.

Complete and submit your Ohio Uniform Authorization Form online today to ensure timely access to necessary services.