Follow the steps to complete the Healthfirst Authorization Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your editor.
2. Fill in the date of request in the format of MM/DD/YYYY.
3. Enter the contact name, phone number, extension (if applicable), and fax number in the designated fields.
4. Provide the member ID number, first and last name, and date of birth (DOB) of the member in the specified fields.
5. In the requesting provider section, enter the first and last name of the provider, and check the box if requested by the primary care physician (PCP). Include the provider's phone and fax number.
6. Check the applicable request types for out-of-network specialist referrals and complete the required information, including service dates and the number of office visits.
7. For the performing provider section, enter their name, specialty, NPI number, Tax ID number, address, phone, and fax information.
8. Indicate the type of service being requested (e.g., office, outpatient, inpatient) and complete the other relevant fields.
9. If applicable, provide detailed information for durable medical equipment (DME) or prosthetics, including supplier name, equipment description, and HCPCS code.
10. Enter diagnosis description, diagnosis codes (ICD-CM), procedure description, and procedure codes (CPT/HCPCS). Include service dates and expected discharge dates as necessary.
11. Complete any additional fields related to hip or knee arthroplasty, including joint class completion.
12. If expedited review is necessary, check the appropriate box and ensure all criteria for accelerated decision-making are met.
13. Review all completed information for accuracy, then save your changes. You can choose to download, print, or share the form as needed.

Complete your Healthfirst Authorization Form online to ensure prompt processing of your request.