Get Staywell Prior Authorization Form

Filling out the Staywell Prior Authorization Form is an essential step in ensuring that necessary medical procedures, treatments, or medications are covered. This guide provides a detailed, step-by-step walkthrough of the form's components to assist users in completing it accurately and efficiently.

Follow the steps to properly complete the Staywell Prior Authorization Form online.

1. Press the ‘Get Form’ button to access the Staywell Prior Authorization Form and open it for editing.
2. Complete the 'Priority' section by selecting the appropriate option: Standard, Date of Service, or Urgent, depending on the urgency of the request.
3. In the 'Patient Information' section, fill in the patient's name, gender, height, weight, address, phone number, health plan ID, and date of birth.
4. Provide details in the 'Ordering Physician/Clinic Information' section, including the physician's name, TIN/NPI number, specialty, contact name, clinic name, address, and phone number.
5. If applicable, fill out the 'Rendering Physician/Clinic/Facility/Pharmacy Information' section. If the information is the same as the ordering physician, check the appropriate box.
6. Describe the requested medical procedure or treatment in the 'Requested Medical Procedure/Course of Treatment/Device Information' section, selecting the service type and setting.
7. In the 'HCPCS/CPT/CDT Codes' section, enter the latest ICD code, HCPCS/CPT/CDT code, code description, and medical reason for the request. Attach any relevant clinical documentation.
8. Complete the 'Other Services' section if applicable, including details about the type of service, therapy agency name, requested units, and the frequency or length of time needed.
9. In the 'Prescription Drug' section, provide the diagnosis name, medication requested, strength, dosing schedule, quantity per month, and medical rationale for selecting the medication.
10. Document any previous services or therapies in the 'Previous Services/Therapy' section, including dates and reasons for discontinuation.
11. Finally, complete the 'Attestation' section by signing and dating the form, certifying that all information is accurate.
12. Once all required fields are completed, save your changes, download the form, and print or share it as needed.

Take action today by filling out the Staywell Prior Authorization Form online to ensure timely processing of your medical needs.