To prevent delays in processing your prior authorization request, fill out this form in its entirety 2026

1. Click ‘Get Form’ to open it 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 completely, including name, Empire ID, date of birth, and contact details.
4. Provide details for both the referring provider and servicing provider sections. Indicate whether they are participating or nonparticipating providers.
5. In the requested service section, enter relevant ICD-10 and CPT codes along with the date or date range of service.
6. Select all applicable types of service and place of service by checking the appropriate boxes.
7. Complete any additional information required, such as marking if the request is emergent or urgent.

Start using our platform today to ensure your prior authorization requests are processed smoothly and efficiently!