NM Uniform Prior Authorization Form 2026

1. Click ‘Get Form’ to open the NM Uniform Prior Authorization Form in the editor.
2. Begin by filling out the 'Priority and Frequency' section. Indicate whether the request is Standard or Urgent/Expedited, and provide any necessary details regarding frequency and previous authorization numbers.
3. In the 'Enrollee Information' section, enter the enrollee's name, date of birth, subscriber/member ID, and address details accurately.
4. Complete the 'Provider Information' section by selecting whether you are the Ordering Provider, Rendering Provider, or both. Fill in all required fields including provider name, type/specialty, NPI number, and contact information.
5. For the 'Requested medical or behavioral health course of treatment/procedure/device information', describe the service requested and select the appropriate setting.
6. Fill in the 'HCPCS/CPT/CDT/ICD-10 CODES' section with relevant codes and medical reasons for your request.
7. If applicable, answer questions about frequency/quantity requests in Section 6. Specify if multiple treatments are involved and provide details on therapy/agencies as needed.
8. Complete any sections related to prescription drugs if applicable. Provide diagnosis codes, medication requested, dosing schedules, and any relevant clinical rationale for your request.
9. Finally, review all entered information for accuracy before signing in the 'Attestation' section to certify that all provided information is true.

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