Follow the steps to complete the NM Uniform Prior Authorization Form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section 1, indicate the priority of the request by selecting either 'Standard' or 'Urgent/Expedited'. If necessary, provide the previous authorization number.
3. Complete Section 2 with the enrollee's information, including name, date of birth, member ID, street address, city, state, and zip code.
4. In Section 3, provide the ordering and/or rendering provider information, including provider name, type, NPI number, contact details, and if applicable, DEA number.
5. Section 4 requires a description of the requested medical or behavioral health treatment. Specify the setting by checking the appropriate boxes.
6. Fill in Section 5 with the necessary HCPCS/CPT/CDT/ICD-10 codes, medical reason, and latest ICD-10 code.
7. In Section 6, answer whether the treatment involves multiple services, and specify the type of service and quantity required.
8. If applicable, complete Section 8 with details about the prescribed medication, including diagnosis, height, weight, route of administration, dosing schedule, and known drug allergies.
9. Section 9 is where you attest that the information provided is true. Sign and date the form.
10. Once all sections are completed, review your entries for accuracy. You can then save changes, download, print, or share the completed form.

Start filling out your NM Uniform Prior Authorization Form online to ensure a smooth authorization process.