Follow the steps to complete the HWMG Precertification Request Form online

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Enter the date in the designated field to indicate when the request is being submitted.
3. Fill in the 'FROM' section with your details if you are the person making the request.
4. Under 'RE', provide the name of the contact person if it is not the physician making the request.
5. Input the requesting physician’s name in the relevant section.
6. Enter the EIN or SSN in the appropriate field.
7. Provide the name of the patient for whom the precertification is being requested.
8. Select the patient's sex by marking either 'Male' or 'Female'.
9. Fill in the name of the subscriber responsible for the patient’s health plan.
10. Add the patient's fax number in the specified field.
11. Enter the patient's date of birth using the format mm/dd/yy.
12. Input the member ID number associated with the patient's health plan.
13. Write down the diagnosis using the corresponding ICD-10 codes.
14. Specify the requested services by including the relevant CPT or HCPCS codes.
15. Provide anticipated date(s) of service in the fields provided.
16. If applicable, enter the anticipated date of surgery.
17. If applicable, fill in the anticipated date of admission.
18. Designate the name of the facility providing the requested service.
19. Include pertinent clinical information or medical justification for the requested service in the specified area.
20. To minimize delays, ensure you attach all necessary supporting documentation, such as medical history and treatment plans.
21. Once all fields are completed and reviewed for accuracy, you can save the changes, download, print, or share the form as needed.

Complete your HWMG Precertification Request Form online today!