Nyc healthline fax authorization request 2025

1. Click ‘Get Form’ to open the NYC Healthline Fax Authorization Request in the editor.
2. Begin by filling out the Member/Subscriber information section. Enter the last name, first name, ID number, and date of birth (MMDDYYYY) for the member.
3. Next, provide Patient information. Fill in the patient's last name and select their relationship to the member: Self, Spouse, or Child.
4. Indicate the requested length of stay in days and check one service per fax form from the options provided such as Inpatient acute or Outpatient therapy.
5. Complete the Diagnosis/Procedure information by entering primary and secondary diagnoses along with their respective ICD–10 codes and procedure CPT–4 code.
6. Fill out Facility/Provider information including name, address, NPI, city, state, and ZIP code.
7. Lastly, provide details for the ordering physician including their name and phone number. Review all entries for accuracy before submission.

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