Previous Authorization Number: 2026

1. Click ‘Get Form’ to open the Previous Authorization Number: in the editor.
2. Begin with SECTION I: PATIENT INFORMATION. Fill in the patient's last name, first name, address, date of birth (DOB), city, state, and zip code.
3. Move to SECTION II: REQUESTING PROVIDER INFORMATION. Enter details such as the requesting provider's name, contact person, TIN, phone number, address, fax number, specialty type, group name, and select whether the request is routine or urgent.
4. In SECTION III: TYPE OF CARE REQUEST, provide the diagnosis using ICD 10 codes and describe the requested service including CPT/HCPCS codes. Indicate if this is a referral to another specialty and fill out servicing provider information if applicable.
5. Proceed to SECTION IV: TYPE OF SERVICES REQUESTED. Specify services like PT, OT, speech therapy or surgical procedures along with frequency and duration.
6. Complete SECTION V: CLINICAL INFORMATION by attaching necessary documentation that supports medical necessity for services requested.
7. Finally, if applicable, fill out SECTION VI: DISCHARGE NEEDS for inpatient admissions or procedures detailing any additional needs.

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