Get Nj Horizon Health Dme Authorization Request Form 2016-2025

Filling out the NJ Horizon Health DME Authorization Request Form online can be a straightforward process if you have the necessary information at hand. This guide will walk you through each section of the form, ensuring that you can complete it accurately and efficiently.

Follow the steps to complete the authorization request form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the Date of Request in the designated field. This should reflect the current date you are submitting the form.
3. Provide the Member Name, Member ID, address, and phone number in the General Information section. Ensure all details are current and accurate.
4. Input the DME Provider Name, along with the contact person's name, phone number, and fax number under the DME Provider section.
5. Specify the Date of Birth of the member to assist in identifying the individual.
6. In the Required Information section, enter the details of the DME being requested, including the HCPC/CPT code and quantity needed. Add the name of the Ordering Physician, along with their Provider ID and NPI number.
7. For the Authorization Information, specify if this is an Initial Authorization Request or an Auth Extension Request. If applicable, provide the previous authorization number.
8. Any additional comments or notes relevant to the request can be entered in the Comments section.
9. Once all sections of the form are filled out, review your entries for accuracy, save any changes made, and follow your preferred method to download, print, or share the completed form.

Complete your NJ Horizon Health DME Authorization Request Form online today for a seamless submission process.