Follow the steps to complete the form with ease.

1. Click the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Enter today's date in the designated field to indicate when you are completing the request.
3. Fill in the appointment date, ensuring you select a date that aligns with the availability of the healthcare services you are requesting.
4. Provide the member's name as registered with the health plan. This should be the individual who is seeking authorization for the office visit.
5. Input the member's date of birth in the appropriate format. This information helps verify the identity of the member.
6. Select the relevant health plan from the list or specify if it is not mentioned.
7. Fill in the member ID number. This is crucial for the processing of the authorization request.
8. Identify the referring physician by entering their name. This ensures the request is directed correctly.
9. Indicate the date of the last examination to provide context to the request being made.
10. Complete the section indicating with whom the member is scheduled to see, including the specific office visit or testing being requested.
11. For diagnoses, enter the appropriate ICD codes, distinguishing between those before and after October 1, 2015.
12. Mark whether this is for an office visit or testing only.
13. Include any relevant CPT codes associated with the treatments or procedures suggested.
14. Detail the treatment plan or procedure being requested in the space provided.
15. Specify the number of visits requested, ensuring it aligns with the treatment plan.
16. In the section provided, insert the fax number to which the authorization should be sent. Double-check for accuracy.
17. Attention: Fill in the appropriate individual's name or department that should receive the faxed authorization.
18. Review all entered information for accuracy and completeness before proceeding to submit.
19. Once completed, you can save changes, download a copy for your records, print the form, or share it as necessary.

Start completing your OFFICE VISIT AUTHORIZATION REQUEST FORM online today for a seamless healthcare experience.