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Click ‘Get Form’ to open it in the editor.
Begin by entering the 'Date of Request' at the top of the form. This helps track when your authorization request was made.
Fill in the 'General Information' section with the member's name, ID number, address, and phone number. Accurate details ensure proper processing.
Provide information about the DME provider, including their name, contact person, phone number, and fax number.
In the 'Medical Information Needed' section, specify the date or date range of service and list primary and chronic diagnoses along with corresponding ICD 10 codes.
Complete the 'Required Information' section by detailing DME items needed, including HCPC/CPT codes and quantities.
Finally, fill out any authorization requests or comments before submitting your completed form securely through our platform.
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To submit a Prior Authorization or an Exception Request, your provider can either print and fax the forms (fax: 385-425-4052) for review or submit the request
Step-by-step guide for prior authorization | Washington State
This section provides information on: How to submit an authorization request. For more information contact: 1-800-782-5150, ext. 1. Fax your request to the
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