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Dental Hospitalization Authorization Form (OHP and Medicare) 2026
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- Click ‘Get Form’ to open the Dental Hospitalization Authorization Form in the editor.
- Begin by filling out the 'Person Completing the Form' section. Enter your name, date, phone number, and fax number. Indicate whether you are working at a PCP office or a Specialist Office.
- Next, complete the 'Member Name' section. Provide the last name, first name, middle initial, date of birth, and subscriber ID of the member.
- In the 'Provider Names' section, input the specialist's name, clinic name, facility name, and tax ID number.
- Fill out the 'Diagnosis (Dx) / Procedure Information' section by entering primary and secondary diagnoses along with their respective codes and procedures.
- Address any comorbid conditions by answering yes or no to whether there is a comorbid medical condition that requires attention. If yes, provide details including diagnosis code and narrative.
- Finally, specify the level of care requested by indicating whether it is hospital inpatient along with anticipated admit date and number of days.
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Related links
Download, The United States Government Manual. Open PDF In Browser, View PDF. The United States Government Manual Getting Started To begin searching withinRead more
For providers not enrolled with OHP, complete and submit the OHP 3113 form to OHP Provider Enrollment. Prior Authorization Handbook provides step-by-step
Jan 1, 2022 Youll need it for: Medical appointments Dental appointments approval required Approval based on OHP guidelines. extra dental benefits.