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Click ‘Get Form’ to open the alohacare prior auth form in the editor.
Begin by entering the MEMBER ID, PCP NAME, and your personal details including NAME, PHONE, and D.O.B. Ensure all information is accurate for processing.
In the REFERRAL section, select the appropriate referral category by checking the box and specify the referral effective date range. If left blank, it will default to one year from the request date.
For treatment requests requiring prior authorization, attach any necessary clinical notes or documentation that supports medical necessity. Fill in details such as ICD-9 CODE(S), DIAGNOSIS, and CPT/HCPCS CODE for requested services.
Complete any additional sections relevant to travel requests or companion requests if applicable. Make sure to provide all required information for a smooth approval process.

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2008	4.8 Satisfied (105 Votes)

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