DE AmeriHealth Caritas ACDE-17122384 2026

1. Click ‘Get Form’ to open the DE AmeriHealth Caritas ACDE-17122384 in the editor.
2. Begin by filling out the MEMBER INFORMATION section. Enter the patient's name, date of birth, Medicaid/health plan number, and last authorization number if applicable.
3. Next, move to the PROVIDER INFORMATION section. Input the provider's name and select whether they are in-network, out-of-network, or in the credentialing process. Fill in the group or agency name and provider credentials.
4. Complete the DIAGNOSES section by entering primary, secondary, and tertiary diagnoses as needed. Specify the number of visits requested and their frequency.
5. Fill in CPT/HCPC codes, start date, estimated end date, and ensure you provide a signature from the provider before submitting.
6. Finally, submit your completed form to Behavioral Health Utilization Management via fax at 1-877-234-4273.

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