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Highmark Blue Shield Outpatient Authorization Request 2026
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- Click ‘Get Form’ to open the Outpatient Authorization Request in our editor.
- Begin by entering the Patient’s Name, Phone Number, and Address in the designated fields. Ensure all information is accurate for processing.
- Fill in the Date of Birth and Member UMI along with the Suffix Number. This information is crucial for identification.
- Provide details for the Requesting Physician including their Name, Address, and Contact Information. This ensures proper communication regarding the authorization request.
- 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).
- For MRI or PET Scan requests, indicate any specific requirements (e.g., With Contrast) by checking the relevant options.
- 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.
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Related links
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