Ohio Provider Medical Prior Authorization Request Form - CareSource 2026

1. Click ‘Get Form’ to open the Ohio Provider Medical Prior Authorization Request Form in our editor.
2. Begin by filling out the 'Patient Information' section. Indicate whether the request is routine or urgent, and provide the date of request, member ID, name, address, date of birth, and phone number.
3. Attach any necessary clinical notes that detail the patient's history and prior treatments. Specify if the request is for inpatient or outpatient services.
4. Complete the 'Ordering Provider' section with your name, tax ID, NPI, phone number, fax number, and address. Include the date of service requested.
5. Fill in details about the facility or service provider including their name and contact information. Provide diagnosis codes (ICD-9) and descriptions as needed.
6. List requested procedures or services along with their corresponding procedure codes (CPT/HCPCS) and quantity. If applicable, indicate durable medical equipment details.
7. Complete any additional sections regarding other liability insurance and ensure to sign off on who completed the form before submission.

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