Healthfirst outpatient authorization form 2025

1. Click ‘Get Form’ to open the healthfirst outpatient authorization form in the editor.
2. Begin by filling out the 'Ordering Provider Information' section. Enter the first and last name, contact phone number, and specify if the ordering provider is a PCP or Specialist. Include the clinic name and specialty as needed.
3. Next, complete the 'Patient Information' section by entering the patient's first name, last name, and CHPW Member ID.
4. In the 'Service Provided By' section, provide details about the service provider including their first and last name, tax ID, facility name, specialty, and contact information. Indicate whether they are participating or non-participating.
5. Specify the clinical urgency of your request by selecting either 'Routine' or 'Urgent'. Fill in the date of service and any diagnosis codes required.
6. List the services being requested along with their corresponding CPT/HCPCS codes and descriptions. If applicable, indicate how many visits are needed and for what duration.
7. Finally, review all entered information for accuracy before submitting your request through our platform.

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