Form online 2026

1. Click ‘Get Form’ to open the Outpatient Authorization Request in our editor.
2. Begin by entering the Patient’s Name, Phone Number, and Address in the designated fields. Ensure all information is accurate for processing.
3. Fill in the Date of Birth and Member UMI along with the Suffix Number. This information is crucial for identification.
4. Provide details for the Requesting Physician including their Name, Address, and Contact Information. This ensures proper communication regarding the authorization request.
5. Select the Type of Service required by checking the appropriate box (e.g., DME, Therapies). If applicable, specify additional details such as Diagnosis Code(s) and Procedure Code(s).
6. For MRI or PET Scan requests, indicate any specific requirements (e.g., With Contrast) by checking the relevant options.
7. Review all entered information for accuracy before submitting. Once complete, fax your form to Clinical Services at 888-236-6321 or follow mailing instructions provided.

Start filling out your Outpatient Authorization Request today using our platform for free!