Buckeye prior auth form pdf 2026

1. Click ‘Get Form’ to open the buckeye prior auth form in our platform.
2. Begin by filling out the MEMBER INFORMATION section. Enter your name, ID number, date of birth, group number, address, and phone number clearly to avoid any delays.
3. Next, move to the REFERRING PROVIDER section. Input the provider's name, NPI number, phone number, TAX ID number, and indicate if they are a participating provider.
4. In the PROVIDER/FACILITY TO PERFORM SERVICE section, provide details about the facility performing the service. If it’s the same as above, check the box provided.
5. For TYPE OF SERVICE(S) REQUESTED, select all applicable services by checking the corresponding boxes. Ensure you review any specific requirements for out-of-network requests.
6. Fill in CLINICAL INFORMATION with procedure codes and diagnosis codes as required. This information is crucial for processing your request.
7. Complete ADDITIONAL CLINICAL INFORMATION by providing start and end dates along with frequency of services needed.
8. Finally, choose between STANDARD REVIEW or EXPEDITED REVIEW based on urgency and sign if necessary before submitting via fax or phone as indicated.

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