Medical treatment authorization request form 2026

1. Click ‘Get Form’ to open the Medical treatment authorization request form in the editor.
2. Begin by filling out the 'Provider Use Only' section. Enter your name, phone number, facility name, fax number, address, group NPI, city, state, ZIP code, and tax ID.
3. Indicate the urgency of the request by selecting either 'Urgent' for potentially life-threatening conditions or 'Routine' for non-life-threatening but important health issues.
4. In the 'Member Information' section, provide the member's name (first and last), address, CIN, city, date of birth, state, ZIP code, and gender.
5. Fill in the medical details including ICD-CM codes and diagnosis descriptions. Ensure you provide a clear medical justification for the requested services.
6. List the services requested along with their corresponding CPT codes/HCPCS. Include any modifiers if applicable and specify the quantity and charges.
7. Finally, ensure that all information is accurate before signing. The physician or provider must sign and date the form to validate it.

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