Get Simply Healthcare Request For Services Requiring Preauthorization Form 2013-2025

Filling out the Simply Healthcare Request for Services Requiring Preauthorization Form online is an essential step for securing necessary healthcare services. This guide provides a detailed walkthrough of each section of the form to ensure accurate and efficient submission.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering the member's full name in the designated field. This ensures that the request is linked to the correct individual.
3. Fill in the ‘Simply Healthcare Plans ID #’ field with the member's identification number for accurate tracking.
4. Indicate the specialty of the service required in the ‘Specialty’ section to notify the relevant department.
5. Provide the member's date of birth and telephone number in the respective fields to maintain updated contact information.
6. Specify if the referral is from an in-network or out-of-network provider by selecting the appropriate checkbox.
7. Enter the primary care physician (PCP) name and ID number, along with their telephone number, to identify the member's healthcare provider.
8. Include the referring physician's name and contact information to ensure proper communication regarding the service request.
9. List all relevant diagnosis codes in the ‘Diagnosis (ICD-9)’ section, ensuring all conditions are accurately represented.
10. Enter the corresponding CPT codes to support the diagnosis and requested services effectively.
11. Outline the reason for the referral clearly in the space provided to justify the necessity of the requested services.
12. Indicate the fax number for the referring physician in case further documentation or communication is needed.
13. Specify the type of request (standard or expedited) by selecting the appropriate option to indicate urgency.
14. Confirm if the request is initial, second, or third, and indicate if it is related to an accident by selecting ‘Yes’ or ‘No’. If applicable, specify the type of accident.
15. Report any other insurance coverage the member may have, including Medicaid, to ensure comprehensive communication with insurance providers.
16. Complete the section detailing the services requiring preauthorization and ensure all supporting clinical documentation is attached.
17. Finally, save changes made to the form and choose to download or print a copy for your records, or share it with the required parties.

Start completing your Simply Healthcare Request for Services Requiring Preauthorization Form online today for timely healthcare access.