C4 auth form 2025

1. Click ‘Get Form’ to open the c4 auth form in the editor.
2. Begin by filling in the WCB Case # and Claim Administrator Claim (Carrier Case) # at the top of the form. Ensure these numbers are accurate as they are crucial for processing your request.
3. In section A, provide the patient's name, address, date of injury/illness, and Social Security number. This information is essential for identifying the patient and their claim.
4. Next, enter the attending doctor's details in section B, including their name, address, NPI number, and contact information. This ensures that all communications regarding authorization are directed appropriately.
5. In section C, specify the services requested that require authorization. Clearly indicate whether each service is granted or denied by checking the appropriate boxes.
6. Complete the Statement of Medical Necessity section by providing a detailed explanation justifying why these services are necessary for the patient's treatment.
7. Finally, ensure you submit this form to the designated insurer/self-insurer's contact via fax or email as indicated on our platform to avoid any delays in processing.

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