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Click ‘Get Form’ to open the OH-PARequestForm-Availity Accessible PDF in our editor.
Begin by entering the 'Date of Request' at the top of the form. This is essential for tracking your request.
Fill in the 'Member Information' section, including the member's name, date of birth, and ID number. Ensure accuracy for proper identification.
In the 'Requesting Physician or Provider Information' section, provide details about the referring provider, including their name, address, and contact information.
Complete the 'Referral / Authorization Information' by detailing the problem/diagnosis using ICD-10 codes and specifying any requested procedures/tests with CPT codes.
Lastly, include any additional clinical information that may support your request. Attach extra pages if necessary.
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