Indiana university health form 2026

1. Click ‘Get Form’ to open the Indiana University Health Authorization Request Form in our platform.
2. Begin by filling out the 'Requesting Physician Information' section. Enter the Ordering MD's name, vendor details including Tax ID, address, and contact information.
3. Next, complete the 'Member Information' section. Provide the member's name, ID number, date of birth, social security number, and phone number.
4. In the 'Date of Service' field, specify when the service is requested. Fill in the CPT or HCPC code and describe the requested service.
5. Indicate whether services are approved as requested, modified, or denied. If modified or denied, provide details in the designated area.
6. Complete the 'Clinical Summary' section thoroughly; this is mandatory for form acceptance. Attach any necessary documents if required.
7. Finally, ensure that you sign and date at the bottom of the form before submitting it via fax to IUHMM.

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