Standardized Prior Authorization Form Instructions - Well Sense 2025

1. Click ‘Get Form’ to open the Standardized Prior Authorization Form in the editor.
2. Begin by entering the date at the top of the form. This is essential for tracking your request.
3. Fill in the Member Information section, including the member's name, date of birth, member ID number, and contact details.
4. In the Submitted by/Sender Information section, provide your name and any relevant provider information.
5. Complete the Provider Information section with details about the requesting provider and servicing facility, ensuring all NPI numbers are accurate.
6. For Requested Services, check off the appropriate reason for visit and fill in required codes for diagnosis and CPT as needed.
7. If applicable, specify details for surgery or outpatient rehab services, including dates and number of visits required.
8. Finally, review all sections for completeness before submitting. Attach any necessary clinical information to avoid delays.

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