Get Preauthorization/ Rqi Request Fax Form If Urgent Request Please Call Aim Please Complete All

This guide provides clear and supportive instructions for filling out the PREAUTHORIZATION/ RQI REQUEST FAX FORM. Ensuring all sections are completed accurately will help streamline the processing of your request.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the appropriate editor.
2. Fill in the ‘To’ section with ‘American Imaging Management PREAUTH/RQI Department’. Include the fax number '800-610-0050' and the name of the person submitting the request.
3. Complete your contact information in the ‘From’ section, including your name, phone number, and fax number.
4. Provide the ‘Subscriber and Patient Information’ by entering the patient’s name, subscriber’s name, ID number, date of birth, and social security number as instructed.
5. Indicate the relationship of the patient to the subscriber and specify the gender by selecting from the options available.
6. In the ‘Health Plan Name’ section, fill out the health plan name, group number, and product type by selecting from the provided options.
7. Complete the ‘Referring Physician Information’ by entering the physician's name and contact details.
8. Input the provider information, which includes the name and address of the facility where the service will be provided.
9. In the ‘Procedure(s) Information’ section, enter details of the procedure including date and CPT code if it is available.
10. Provide all necessary clinical information in the designated section, addressing each question regarding diagnosis, suspected conditions, treatments received, previous testing, injury relatedness, and cancer protocol.
11. Once all fields are filled out, review the form for completeness and accuracy to ensure no information is left out. Incomplete forms will be returned.
12. Save changes, download, print, or share the completed form as necessary.

Complete your PREAUTHORIZATION/ RQI REQUEST FAX FORM online today for timely processing.