Preauthorization/RQI Request Fax Form 2026

1. Click ‘Get Form’ to open the Preauthorization/RQI Request Fax Form in our editor.
2. Begin by filling out the 'FROM' section with your contact information, including your name, phone number, and fax number.
3. In the 'Subscriber and Patient Information' section, enter the patient's name, subscriber's name, ID number, date of birth, and social security number. Specify the relationship to the subscriber and select the sex.
4. Complete the 'Health Plan Name' and 'Group Number' fields. Indicate the product type by selecting from options like PPO, HMO, etc.
5. Fill in the 'Referring Physician Information' with the physician's name and specialty. Provide their contact details as well.
6. In the 'Procedure(s) Information' section, list all procedures along with their dates and CPT codes if available.
7. Complete the 'Clinical Information' section by providing detailed answers regarding diagnosis, treatment history, previous testing results, injury-related questions, and cancer protocol inquiries.

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