Form la paf 0658-2026

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4 out of 5

46 votes

The document is an Outpatient Prior Authorization Fax Form used to request additional units for existing authorizations. It outlines the process for standard and urgent requests, requiring specific member and provider information, procedure codes, diagnosis codes, and service types. The form emphasizes the need for complete information and supporting clinical documentation to avoid delays in determination. It also includes a disclaimer about authorization not guaranteeing payment and highlights confidentiality under HIPAA.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the member information. Fill in the Member ID/Medicaid ID and Date of Birth in the required fields marked with an asterisk (*).
Next, provide the requesting provider information. Enter the Requesting NPI, TIN, Contact Name, and Phone number.
For servicing provider/facility information, if applicable, check 'Same as Requesting Provider' or fill in the Servicing NPI and TIN along with contact details.
In the authorization request section, complete all required fields including Primary Procedure Code, Diagnosis Code, and Total Units/Visits/Days.
Select the Outpatient Service Type by entering the corresponding service type number from the provided list.
Ensure all required fields are filled out completely to avoid rejection. Attach any necessary supporting clinical information before submission.

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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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Does Medicare Part B require prior authorization?

Some Part B drugs require prior approval before they can be administered. This is called precertification or prior authorization. This helps us review a drug to ensure its safe and appropriate for your patient. Our medical precertification lists feature the latest information, including Part B drugs.

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