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1. Click ‘Get Form’ to open the document in the editor.
2. Begin by entering the Member Name and Date of Birth in the designated fields. Ensure accuracy as this information is crucial for processing.
3. Fill in the Insurance Identification Number and Member Phone Number. This helps in identifying the member's insurance details.
4. Provide details for the Ordering Provider, including Name, Specialty, Provider ID Number, Office Address, Phone Number, and Fax Number.
5. Repeat the process for the Rendering Provider’s information. Make sure all fields are completed accurately.
6. Enter Facility Name, ID Number, and Address. Specify the Date/Date Range of Service and Service(s) Requested (CPT if known).
7. Indicate Place of Service (Observation, Outpatient, Inpatient, Other) and provide Diagnosis (ICD-9 if known).
8. Describe the service being requested using CPT/HCPCS codes and detail the member's condition related to this request.
9. Complete the attestation section by providing your name and title. Ensure that all required clinical information is submitted at least three business days before the procedure.

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