Precertification request form 2026

1. Click ‘Get Form’ to open the precertification request form in the editor.
2. Begin by entering today’s date and the provider return fax number at the top of the form.
3. Fill out the member information section, including first name, last name, Amerigroup member ID, address, city, state ZIP code, date of birth (DOB), and contact phone number.
4. Complete the referring provider section by indicating if they are participating or nonparticipating. Provide their full name, NPI, provider ID, tax ID number (TIN), office contact name, office phone and fax numbers, address, city, state ZIP code, and specialty.
5. Repeat step 4 for the servicing provider section. Ensure all relevant details are accurately filled in.
6. In the servicing facility section, indicate participation status and provide necessary details such as facility name, NPI, provider ID, TIN, contact name and phone number.
7. Specify requested services by checking all applicable types and providing dates of service along with ICD-10 and CPT codes.
8. Include any additional information required for your request at the end of the form before submission.

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