Get Alignment Health Prior Authorization Request 2014-2025

Completing the Alignment Health Prior Authorization Request is an important step in ensuring that your healthcare needs are met in a timely manner. This guide provides clear, step-by-step instructions to assist users in filling out the form completely and accurately.

Follow the steps to successfully submit your request

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Begin by entering the practice location and date at the top of the form. Include the name of the primary care provider (PCP) and indicate whether the request is urgent or routine by selecting the appropriate checkbox.
3. Fill in the health plan member identification number and the patient's details, including their name, address, city, state, zip code, date of birth, and telephone number. Make sure to print the name clearly to avoid any errors.
4. Select the type of service required by circling one of the options provided, such as hospital, outpatient, inpatient, specialty office, durable medical equipment (DME), skilled nursing facility (SNF), home health, dialysis, or chemotherapy.
5. Indicate the diagnosis by entering any relevant details and the corresponding ICD-9 code(s) in the designated space.
6. Describe the procedure along with the appropriate CPT code(s). Ensure that you provide all necessary codes for clarity.
7. In the clinical justification section, attach any pertinent progress notes or diagnostic studies that support the request. Detail any information that would assist in the approval of the authorization.
8. Complete the section for the referring physician by writing their name and telephone number. Additionally, the person completing the form should provide their name, telephone number, and fax number.
9. Once all sections are filled out carefully, review the form for completeness and accuracy. Save changes if you are using digital tools, and ensure that all required information is included.
10. Finally, submit the form as instructed — typically through fax — and ensure you keep a copy for your records.

Start your process by completing the Alignment Health Prior Authorization Request online today.