Follow the steps to complete the HWMG HM Ext-10 04 0104 online.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Fill in the date at the top of the form to indicate when the request is submitted.
3. Provide the name of the patient, ensuring that you enter their full legal name as it appears in their identification.
4. Indicate the patient's sex by selecting either 'Male' or 'Female'.
5. Enter the patient's date of birth in the format mm/dd/yy.
6. Fill in the member ID number associated with the patient’s insurance.
7. Input the diagnosis using the appropriate ICD-9 codes along with a description of the diagnosis.
8. Specify the requested services by including the relevant CPT, HCPCS, or NDC codes, along with descriptions for each service.
9. If applicable, provide the anticipated date(s) of services and if surgery is anticipated, include the date of surgery.
10. Name the facility that will provide the service(s) to the patient.
11. Detail any pertinent clinical information or medical justification for the requested services.
12. Attach supporting documentation required for the request, such as history & physical, diagnostic reports, and progress notes.
13. If applicable, ensure that outpatient rehab services or home health facilities include a signed treatment plan from the requesting physician.
14. Designate the authorized person by providing their name and contact details.
15. Review all information provided for accuracy and completeness.
16. Once completed, save your changes, and then you can download, print, or share the form as needed.

Complete your pre-certification request online today.