Get Il Prior Authorization For Gender-affirming Services

This guide provides a step-by-step approach for effectively completing the IL Prior Authorization For Gender-Affirming Services form online. Ensuring accuracy and thoroughness in this process is crucial for a successful authorization request.

Follow the steps to complete your form correctly.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. In the Client Information section, fill in details such as the date of birth, full name, address including city, state, and zip code, as well as the phone number. Indicate guardianship status if relevant.
3. In the Diagnosis section, provide all known relevant DSM-5 and ICD-10 diagnoses for the individual. Ensure to highlight the primary diagnosis that necessitates the requested services.
4. For Treatment Services Requiring Prior Authorization, specify the requested service or procedure name, along with its corresponding ICD-10 code and whether it includes genital surgery.
5. List the Recipient's Treatment Team by providing information for the primary care physician and other relevant practitioners. Attach additional details on a separate document if necessary.
6. Complete the Form Signature section by having the responsible staff print their name, provide credentials, sign, and date the form, including their NPI and HFS Provider ID.
7. If applicable, fill out Attestation 1 for the physician, ensuring all conditions are checked, and attach necessary medical documentation to support the request.
8. For requests including genital surgery, complete Attestation 2 for the LPHA, ensuring proper documentation is attached, including a mental health assessment and a signed letter.
9. Review the form for any missing information, then save changes, download, print, or share the form as needed.

Complete your documents online to ensure timely processing of your request.