Get Ia 470-0829 2020-2026

The IA 470-0829 is a Dental Request for Prior Authorization form that must be completed accurately to ensure prompt processing of requests. This guide provides a clear and systematic approach for filling out the form online, helping users navigate each section effectively.

Follow the steps to complete the IA 470-0829 form

1. Press the ‘Get Form’ button to access the form and open it in your digital editor.
2. Enter the patient’s name in the provided fields for last name, first name, and middle initial.
3. Fill in the patient’s Medicaid identification number in the designated section.
4. Provide the patient's date of birth in the format Month/Day/Year.
5. Input the dispensing provider’s name in the appropriate field.
6. Enter the provider's National Provider Identifier (NPI) in the corresponding space.
7. Complete the provider taxonomy number section if applicable.
8. Fill in the service location, including street address, city, state, and zip code.
9. Provide the provider’s phone and fax number in the specified fields.
10. Specify the dates covered by the request, detailing both the start and end dates.
11. Clearly outline the reason(s) for the authorization request. If more space is needed, use an additional sheet.
12. List the services to be authorized, including the line number, procedure or service description, CDT code, units of service, and the amount requested.
13. Leave any fields that require information from the review process, such as authorized amount and status, blank.
14. Sign and date the requesting provider’s signature section, confirming the submission.
15. Once completed, you may save your changes, download the form, print it, or share it as needed.

Complete your IA 470-0829 form online today for efficient processing.