Referral pre-authorization form 2026

1. Click ‘Get Form’ to open the referral pre-authorization form in the editor.
2. Begin by entering the patient's name, date of birth, and member ID in the designated fields. This information is crucial for identifying the patient.
3. Next, provide details about the referring physician by printing their name and including the date of request. This establishes who is initiating the referral.
4. Fill in the referred provider and facility names. Accurate information here ensures that services are directed appropriately.
5. Specify the diagnosis and include the corresponding ICD10 code. This helps in processing the pre-authorization efficiently.
6. List the services requested along with their CPT/HCPC codes. These codes are essential for billing and insurance purposes.
7. For surgery requests, indicate whether it is inpatient or outpatient and provide a date of service.
8. Finally, ensure that a physician signature is included along with their contact information for any follow-up required.

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