Imperial health authorization form 2026

1. Click ‘Get Form’ to open the imperial health authorization form in the editor.
2. Begin by filling in the 'Date Submitted' field at the top of the form. Select whether your request is 'STANDARD', 'URGENT', or a 'MODIFICATION'. If applicable, enter the Authorization number and Date of Service.
3. Complete the 'Referring Provider' section with your name, phone number, and fax number. Indicate the type of service requested by checking one of the options provided (e.g., OFFICE, AMBULATORY SURGICAL CENTER).
4. Fill in the 'Requested Date of Service' and 'Scheduled Admit Date'. Then, provide the member's full name, date of birth, and Member ID number.
5. List any other insurance or worker’s compensation details if applicable. Complete the Primary Care Physician (PCP) section with their name and contact information.
6. In the 'Requested Services' section, enter CPT/HCPCS codes along with quantities for each procedure description you are requesting.
7. Provide diagnosis information by entering ICD codes and descriptions as required.
8. Fill out details for the requested specialist/provider and facility including names, specialties, phone numbers, Tax IDs, and NPI numbers.
9. Finally, ensure to attach any necessary clinical documents that support medical necessity before submitting your completed form.

Start using our platform today to easily fill out your imperial health authorization form for free!