DFEC Authorization Templates - DOLDFEC Authorization Templates - DOLDFEC Authorization Templates - D 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Member Information section. Ensure all fields marked with an asterisk (*) are completed, including Name, Medicaid ID#, Date of Birth, and Age.
3. Indicate the member's gender and verify eligibility by checking the appropriate box. If applicable, confirm if the member is enrolled in a managed care entity (MCE).
4. In the Provider Information section, enter details for the requesting provider, including NPI, address, contact person, and contact information.
5. Complete the Request Information section by answering whether prior authorization is required for the requested code and providing dates of service.
6. Select therapy types requested and indicate the number of visits. Include any additional information as necessary.

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