Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to access the document and open it in your chosen online editor.
2. Complete the 'Member Information' section by entering the member ID/Medicaid ID, date of birth, and last name followed by first name. Ensure all required fields with an asterisk (*) are filled out.
3. In the 'Requesting Provider Information' section, enter the requesting NPI, contact name, TIN, provider name, fax number, and phone number.
4. If applicable, select 'Same as Requesting Provider' for servicing provider information or fill in the servicing NPI, TIN, contact name, fax, and phone number for the servicing provider/facility.
5. Proceed to the 'Authorization Request' section by entering the primary procedure code, start or admission date, and diagnosis code. If necessary, include additional procedure codes as well.
6. In the 'Outpatient Service Type' field, fill in the appropriate service type number. Carefully select from the list provided to avoid errors.
7. Ensure that all required fields are complete, as incomplete forms will be rejected. Check for all necessary supporting clinical documentation as failure to provide these may delay the determination.
8. After reviewing all entries for accuracy, save your changes, and choose to download, print, or share the form as needed.

Complete your authorization requests online to ensure a smoother process.