Prior Auth request bformb Community Phys 1 22 14 - CenterLight bb - centerlighthealthcare 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Date of Request' at the top of the form. This is essential for tracking your submission.
3. Indicate whether this is a 'Standard Request' or an 'Urgent Request' by checking the appropriate box.
4. Fill in your name and contact number in the 'Request Sent By' section to ensure communication regarding your request.
5. Provide the member's full name and ID number, along with their plan type (Direct, PACE, Select) for accurate identification.
6. Specify the referring provider and whether they are a PCP or Specialist, followed by details of the provider you are referring to, including network status.
7. Clearly state the reason for your request and attach any additional clinical information that supports your case.
8. Complete sections for type of service requested, dates of service or number of visits, place of service, diagnosis/ICD9 code, procedure/CPT code, and any reasons for out-of-network requests.

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