Follow the steps to successfully fill out the precertification request form.

1. Press the 'Get Form' button to access the Precertification Request form and open it in your preferred editing program.
2. Begin by entering the date at the top of the form to indicate when the request is submitted.
3. Provide the member information, including their name, Empire ID, date of birth, and contact details.
4. Fill out the provider return fax section with the relevant contact information to ensure proper communication regarding the authorization request.
5. Complete the additional member information section, including any previous authorization numbers and the referring provider's details.
6. Now, input the servicing provider and servicing facility information. Indicate whether they are participating or nonparticipating providers.
7. Detail the requested service by entering the appropriate ICD-10 codes and CPT codes, including requested units.
8. Select the type of service from the options, ensuring you check all that apply to your request.
9. Specify the place of service by selecting the applicable option such as hospital, office, or home.
10. Provide any additional information regarding the request, including urgency indicators like emergent or urgent statuses, as needed.
11. Review all the entered information for accuracy and completeness before finalizing the form.
12. Once all fields are completed, you may save changes, download, print, or share the completed form as necessary.

Take the next step and complete your NY Empire Blue Cross Blue Shield Precertification Request online today.