Incomplete, illegible or inaccurate forms will be returned to sender 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the MEMBER INFORMATION section. Ensure that you provide your full name, member ID, address, city, state, zip code, date of birth, and phone number clearly.
3. In the CC INFO section, enter the Care Coordinator's name and phone number accurately.
4. Complete the ATTENDING HEALTH CARE PROFESSIONAL INFO section with the ICD-10 code and clinician details. Make sure all fields are legible.
5. Fill in the NEW OR CURRENT EW DATE SPAN with accurate dates. This is crucial for processing your request.
6. In the SERVICES/PROCEDURES/ITEMS REQUESTED section, select appropriate options for denial, termination, or reduction and provide a reason code if applicable.
7. Lastly, ensure that all provider information is filled out correctly including name, UCare ID/NPI number, phone number, and fax.

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