Oh paf 0355-2025

1. Click ‘Get Form’ to open the oh paf 0355 in the editor.
2. Begin by entering the Member ID/Medicaid ID in the designated field. This is a required field, so ensure it is filled accurately.
3. Indicate if this is an urgent request by checking the appropriate box and providing a signature from the requesting physician for priority processing.
4. Fill in the member's date of birth using the MMDDYYYY format, followed by their last name and first name.
5. In the Requesting Provider Information section, enter your NPI and TIN numbers, along with your contact name, provider name, phone number, and fax number.
6. If applicable, check 'Same as Requesting Provider' for servicing provider information or fill in their NPI and TIN numbers along with their contact details.
7. Complete the Authorization Request section by entering all required codes (Primary Procedure Code, Diagnosis Code) and dates (Start Date or Admission Date).
8. Select one Outpatient Service Type by filling in only one bubble that corresponds to your request.
9. Review all entries for completeness as incomplete forms will be rejected. Ensure you attach any necessary supporting clinical information before submission.

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