Indiana university health form 2025

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 or modified. If modified, provide details in the designated area.
6. Complete the 'Clinical Summary' section thoroughly; remember that this form will be rejected if not filled out completely. Attach any necessary documents.
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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