Form online 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Member Name, Member ID#, and DOB in the designated fields. This information is crucial for identifying the patient.
3. Fill in the Ordering Provider Name, NPI#, TIN#, and Office Contact Person details. Ensure accuracy as this information is essential for processing.
4. Indicate the Date of Request and provide a Direct Phone # and Fax # for follow-up communications.
5. Input Diagnosis codes (ICD-10) for up to three conditions affecting the member. This helps in justifying the requested services.
6. Select either Standard or Expedited processing based on urgency, and if expedited, ensure to sign below certifying the need.
7. Complete additional sections regarding service type (Inpatient/Outpatient), Specialist Name, Specialty, and Procedure details including CPT codes.
8. Finally, review all entries for accuracy before submitting your form through our platform.

Start filling out your Medical Service Prior Authorization Form online today for free!