Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to retrieve the Buckeye Mycare Prior Authorization Form and open it in your preferred online editing tool.
2. Begin by providing the member information, including the user's name, ID number, date of birth, group number, address, city, state, zip code, and a contact phone number.
3. Next, complete the referring provider section by entering their name, NPI number, phone number, tax ID number, fax number, and indicate whether they are a participating provider by selecting 'Yes' or 'No'. Include a contact name and number if available.
4. For the provider or facility to perform the service, indicate if it is the same as the referring provider. If not, fill in their name, NPI number, phone number, tax ID number, fax number, and status as a participating provider.
5. Select the type of service requested from the provided options, ensuring to mark all that apply. These may include home health services, outpatient therapy, cosmetic procedures, and more.
6. In the clinical information section, fill out the procedure code or CPT/HCPCS modifiers and enter the relevant diagnosis codes.
7. For additional clinical information, specify the start date, end date, waiver code, modifier, units or visits needed, and the frequency (day, week, month).
8. Choose the type of review required: standard (14 calendar days) or expedited (72 hours), and provide a signature in the designated area when necessary, particularly for expedited requests.
9. Once you have filled out all required sections, review the form for completeness. You may then save your changes, download the document, print it, or share it as necessary.

Complete the Buckeye Mycare Prior Authorization Form online today to ensure your requests are processed promptly.