Alignment prior auth form pdf 2025

1. Click ‘Get Form’ to open the alignment prior auth form PDF in the editor.
2. Begin by filling in the 'Practice Location' and 'Date' fields at the top of the form. Ensure that you provide accurate information for efficient processing.
3. Next, enter the 'PCP' (Primary Care Physician) name and select whether the request is 'Urgent' or 'Routine' by checking the appropriate box.
4. Fill in the 'Health Plan Member ID No.' and complete the patient's personal details, including their name, address, city, state, zip code, sex, date of birth, and telephone number.
5. Indicate the type of service required by circling one of the options provided: Hospital, Outpatient, Inpatient, Specialty Office, DME, SNF, Home Health, Dialysis, or Chemotherapy.
6. Provide a detailed diagnosis along with ICD-9 codes and specify the procedure with corresponding CPT codes. This information is crucial for authorization approval.
7. In the 'Clinical Justification' section, attach any relevant progress notes or diagnostic studies that support your request.
8. Complete the details for both the referring physician and person completing the form. Include their names and contact numbers for follow-up.
9. Finally, review all entries for accuracy before submitting. Once completed, fax it to the designated number provided on the form.

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