LHC - Outpatient Prior Authorization Fax Form Outpatient Prior Authorization Fax Form: Fill out & sign online

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Click ‘Get Form’ to open the LHC - Outpatient Prior Authorization Fax Form in the editor.
Begin by filling out the 'Member Information' section. Enter the Member ID/Medicaid ID, Date of Birth, and the member's Last Name and First Name in the required fields.
Next, move to the 'Requesting Provider Information' section. Input your Requesting NPI, TIN, Contact Name, and Phone number. Ensure all required fields are completed.
In the 'Servicing Provider / Facility Information' section, provide details such as Servicing TIN, NPI, and contact information. If applicable, check 'Same as Requesting Provider'.
Complete the 'Authorization Request' section by entering Primary Procedure Code, Diagnosis Code, Total Units/Visits/Days, and any additional procedure codes as necessary.
Finally, review all entries for accuracy. Ensure that all required fields are filled in before submitting to avoid rejection.

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Versions	Form popularity	Fillable & printable
2022	4.9 Satisfied (30 Votes)
2016	4.1 Satisfied (55 Votes)
2015	4 Satisfied (46 Votes)

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