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Click ‘Get Form’ to open the prior authorization fax form in the editor.
Begin by filling out the 'TO' and 'FROM' sections. Enter the recipient's details, including the Health Services Department and your contact information.
Indicate the number of pages being sent, including the cover sheet, and provide the date of submission.
In Section I, enter the issuer's name, phone, and fax numbers as required.
Proceed to Section II to select the review type (Urgent or Non-Urgent) and specify if this is an initial request or an extension/renewal.
Complete Section III with patient information, including their name, date of birth, and member ID number.
Fill out Section IV with provider information for both requesting and servicing providers. Ensure all NPI numbers are accurate.
In Section V, detail the services requested along with relevant codes and diagnoses. Attach any necessary clinical documentation in Section VI.
Start using our platform today for free to streamline your prior authorization requests!
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Please submit your request online (preferred) or by fax. For fax submissions, please include the PDF form and Fax to 801-213-1358. Submit Online Print PDFRead more
This form contains Protected Health Information (PHI) that is protected under HIPAA. Member Information. Last Name: First Name: Date of Birth: Phone Number:.Read more
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