Inpatient Medicare Prior Authorization Fax Form 2026

1. Click ‘Get Form’ to open the Inpatient Medicare Prior Authorization Fax Form in the editor.
2. Begin by filling out the Member Information section. Enter the Date of Birth, Member ID, and ensure all required fields marked with an asterisk (*) are completed.
3. Next, move to the Requesting Provider Information. Input the Requesting NPI and TIN, along with the provider's contact name, phone number, and fax number.
4. Proceed to the Servicing Provider/Facility Information. If it is the same as the requesting provider, check the appropriate box; otherwise, fill in the servicing provider details including NPI and TIN.
5. In the Authorization Request section, enter all relevant procedure codes (CPT/HCPCS), diagnosis codes (ICD-10), and dates as required. Ensure that you provide additional procedure codes if applicable.
6. Finally, review all entries for completeness. Remember that incomplete forms will be rejected. Once satisfied, save your changes and submit via fax as instructed.

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