Follow the steps to successfully complete your authorization request.

1. Press the ‘Get Form’ button to access the document and open it for editing.
2. Begin by entering the member's name, date of birth, and member ID number in the designated fields. Ensure all personal information is accurate to avoid delays.
3. Complete the request date and line of business information if applicable. This establishes the timeframe and category of request.
4. Provide the contact person's name, phone number, and fax number for follow-up inquiries. This information is crucial for communication regarding the authorization request.
5. If applicable, indicate if the provider is non-participating and provide a brief explanation for the out-of-network service request.
6. List the name and NPI number of the service facility along with the servicing and referring provider details, including their TIN and NPI numbers.
7. Determine if the request is expedited. If you are requesting an expedited review, select 'Yes' or 'No' and provide a justification if necessary.
8. Sign the form as the physician, including the date of signature to confirm authorization and responsibility.
9. Select the appropriate service type and enter any relevant codes that correspond to the services being requested.
10. Fill in the service start and end dates to define the period for which the authorization is sought.
11. Input the primary diagnosis codes and relevant procedure/HCPCS codes as needed for your request.
12. Check the boxes for any attached documentation that supports your request, such as clinical notes or lab results.
13. Once all fields are completed, save your changes, download or print your form, and prepare it for faxing to 718-517-2709.

Complete your NY VillageCareMAX Request For Prior Authorization online to ensure timely processing of your request.