Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the ordering provider information. Fill in the first name, last name, contact person at the office, contact fax number, and contact phone number. Indicate if the ordering provider is a specialist or a primary care provider and specify the specialty.
3. Next, complete the patient information section. Enter the patient's first name, last name, middle initial, member ID, date of birth, and retro enrollment date. Indicate if the patient is retro enrolled with CHPW.
4. Fill in the service provider information. Include the first name and last name of the provider, tax ID, and whether they are participating or non-participating. Also, provide the address and specialty of the service provider.
5. In the diagnosis section, provide the relevant diagnosis information. Add the contact fax number and NPI of the service provider, if applicable. Specify whether the request is for outpatient or inpatient services.
6. Indicate the clinical urgency of the request by providing the appropriate codes and descriptions for both primary and secondary diagnoses.
7. List the services being requested. Select whether the request is routine or urgent, and specify the date of service. Indicate if this is a new request or an extension.
8. For each requested service, provide the CPT/HCPCS code and a brief description. If it is an extension request, include the last date of service for reference and specify the duration.
9. Once all sections are completed, review the entire form for any missing information. Attach supporting clinical documentation as required. Incomplete forms will lead to processing delays.
10. Finally, save your changes, download the form, print it, or share it as needed for submission.

Complete the WA CHPW Prior Authorization Request Form online today to ensure timely processing.