1144 instructions request form-2026

1. Click ‘Get Form’ to open the 1144 instructions request form in the editor.
2. Begin by entering the Prior Authorization (PA) No. if applicable, but remember not to write anything in this section as it will be assigned by ACS.
3. In the service description area, utilize the five lines provided to detail and code the services/items requested. If more space is needed, indicate additional pages.
4. Check 'Urgent' only if there is an immediate need for the service/item. Otherwise, select 'New Request' or 'Extension Request' as appropriate.
5. Complete the Recipient Information section with Medicaid I.D., patient details, and address. Ensure all fields are filled legibly.
6. The Physician Section requires a description of services, justification for medical need, and your signature certifying medical necessity.
7. In the Supplier Section, indicate purchase price and any relevant comments. Ensure signatures are provided where necessary.

Start filling out your 1144 instructions request form online for free today!