Get Authorization Form - Community Care Alliance Of Illinois

Filling out the AUTHORIZATION FORM for the Community Care Alliance of Illinois is a crucial step in obtaining necessary services. This guide will walk you through each section of the form, ensuring you provide all required information accurately and efficiently.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to access the authorization form and open it in your preferred online editor.
2. Fill in the request date at the top of the form to identify when the authorization is being requested.
3. In the Enrollee Information section, provide the name of the person needing services.
4. The next section, labeled 'To Be Completed by Plan,' requires the authorization date and effective date. Fill these in accurately according to the authorization timeline.
5. Under Receiving Provider Information, include the provider's name, CCAI ID, and the primary care provider (PCP) name along with their contact information including address, city, state, zip code, phone, and fax number.
6. In the Treatment Requested section, select the appropriate treatment options by checking the relevant boxes such as 'Consult,' 'Surgery,' 'Therapy,' or 'Lab.' Fill in associated codes like ICD and CPT relevant to the requested services.
7. Indicate the desired start date for the services and fill in additional details under the Diagnosis Description. Include the authorization number if applicable.
8. In the Receiving Facility section, provide the necessary information about the facility, including whether it is in-network and their contact details.
9. Fill in the Quantity and End Date for the requested services, and add any additional comments or relevant information in the provided space.
10. Review all filled fields for accuracy, then save the changes, download, print, or share the completed form as needed.

Complete your documents online to ensure a smooth authorization process.