Get Form: Established Ccs/ghpp Client Service Authorization Request ... - Files Medi-cal Ca

This guide provides comprehensive instructions on how to complete the Established CCS/GHPP Client Service Authorization Request form effectively. By following the outlined steps, users can ensure accurate submission for client service authorization.

Follow the steps to fill out the form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Enter the date of request in the provided field. This should reflect the current date when you are making the request.
4. Fill in the provider information: enter the provider's name, provider number, complete address, contact person, contact telephone number, and fax number in the respective fields.
5. In the client information section, provide the client’s name (last, first, and middle), gender, date of birth, CCS/GHPP case number, client index number (CIN), and client’s Medi-Cal number.
7. Indicate the diagnosis by entering the relevant diagnosis codes in the designated field. This may include multiple ICD-9 codes if necessary.
9. Specify if the authorization request is for a new CCS/GHPP SAR or an extension of an existing one. If it is an extension, include the authorization number.
11. For requested services, enter the CPT-4/HCPCS code or NDC code as required, the specific description of the service, and the desired service dates.
13. In the frequency/duration section, indicate how often the service is needed. Also, list the quantity for each procedure.
15. If applicable, check the box to indicate if other documentation is attached and provide the facility name where services will be performed.
17. For inpatient hospital services, complete the related fields such as begin and end dates, number of days, extension dates, and the number of extension days, if applicable.
19. If additional services from other healthcare providers are requested, provide their information including name, provider number, contact details, and the description of services.
21. Once all information is filled out, ensure that the form is signed by the physician or authorized representative before entering the date of the signature.
23. Finally, save your changes, download, print, or share the completed form as necessary.

Start filling out your documents online today for seamless service authorization.