Follow the steps to successfully complete the IA IA-PAF-5879 form.

1. Press the 'Get Form' button to access the IA IA-PAF-5879 online form and open it in your preferred editor.
2. Begin by entering the member's information. You must provide the Medicaid/Member ID, date of birth in MMDDYYYY format, and the last name followed by the first name of the member.
3. Next, you will fill in the requesting provider information. Include the requesting National Provider Identifier (NPI), contact name, Tax Identification Number (TIN), provider name, fax number, and phone number.
4. If the servicing provider or facility is different from the requesting provider, provide their information. Otherwise, you can check the box indicating it is the same as the requesting provider. Include the servicing NPI, contact name, TIN, provider/facility name, phone number, and fax number.
5. For the authorization request section, enter the primary procedure code and any additional procedure codes along with their respective modifiers. Ensure these codes are accurately filled out as they are crucial for processing your request.
6. Select the outpatient service type from the provided list. Enter the service type number in the appropriate boxes. You must also provide the diagnosis code in ICD-10 format, along with the start date or admission date and the end date or discharge date.
7. Finally, indicate the total units, visits, or days required for the requested service. Make sure all required fields marked with an asterisk are completed; incomplete forms may be rejected.
8. Once you have filled out the form, review all provided information for accuracy. After confirming everything is correct, you can save the changes, download, print, or share the completed form as needed.

Complete your IA IA-PAF-5879 form online today for prompt authorization processing!