Authorization is not a guarantee of payment - Neighborhood Health 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the MEMBER INFORMATION section. Enter the Member’s Name, ID #, and Date of Birth (DOB) accurately to ensure proper identification.
3. Next, move to the PROVIDER INFORMATION section. Input the Supplier ID or NPI #, Provider’s Name, Date Request Sent, Date of Service, Previous Auth #, Place of Service (City/Town)/Facility, Provider Contact and Phone #, Provider’s Fax #, and Ordering MD.
4. In the CLINICAL INFORMATION section, provide all necessary supporting documentation and MD orders. Fill in the Diagnosis and Diagnosis Code fields clearly.
5. Complete the NEIGHBORHOOD Section by detailing Quantity (Qty), whether it is for Rent or Purchase, Description and Code Info, Date(s) of Service, CMN Date, Referral #, and indicate if approved or denied.
6. Ensure that the form is signed by a physician in the designated area. Include the date and signature of the Treating Physician.
7. Finally, review all entries for accuracy before submitting. Return the completed form to DMEnsions at (248)844-3824 as instructed.

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