12. FINAL PA_REQUEST_FORM 2026

1. Click ‘Get Form’ to open the 12. FINAL PA_REQUEST_FORM in the editor.
2. Begin by entering the 'Date of Request' at the top of the form. This is essential for tracking your request.
3. Fill in the 'Member Information' section, including your name, ID number, date of birth, and physician's name. If you have other insurance, please include that information as well.
4. Indicate your gender by circling either 'F' for female or 'M' for male.
5. In the 'Requesting Physician or Provider Information' section, provide details for both the referring provider and facility. Ensure to include names, addresses, telephone numbers, fax numbers, specialties, and NPI numbers.
6. Next, complete the 'Referral / Authorization Information' section by detailing the problem/diagnosis using ICD-9 codes and any requested procedures/tests with CPT codes.
7. Specify the date of appointment or service and indicate how many visits are required. Circle the type of procedure: Inpatient, Outpatient, In Office, or Other.
8. Finally, add any additional clinical information necessary in the provided space. Attach extra pages if needed for comprehensive details.

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