Healthfirst outpatient authorization form 2026

1. Click ‘Get Form’ to open the healthfirst outpatient authorization form in the editor.
2. Begin by filling out the 'Ordering Provider Information' section. Enter the first name, last name, contact person, and their phone and fax numbers. Indicate whether the ordering provider is a PCP or Specialist.
3. Next, complete the 'Patient Information' section. Provide the patient's first name, last name, middle initial, date of birth, and CHPW Member ID. If applicable, check the box for 'Patient Retro Enrolled with CHPW' and include the retro enrollment date.
4. In the 'Service Provided By' section, fill in details about the service provider including their name, tax ID, address, specialty, contact phone and fax numbers. Specify if they are participating or non-participating.
5. Indicate the clinical urgency of your request by selecting either 'Routine' or 'Urgent'. Fill in the date of service and provide diagnosis codes along with descriptions for primary and secondary diagnoses.
6. List all services being requested by entering CPT/HCPCS codes along with their descriptions. Specify number of visits and duration as needed.
7. Finally, review all entered information for completeness before submitting your form to ensure timely processing.

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