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How to use or fill out Authorization Request LASALLE INLAND EMPIRE Form 11-16-2012doc - portal nmm with DocHub

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Click ‘Get Form’ to open it in the editor.
Begin by filling in the 'Referral Request Date' at the top of the form. Ensure this date is accurate as it is crucial for processing your request.
Select the urgency of the request by circling either 'Routine', 'Urgent', or 'Retro'. This will help prioritize your referral appropriately.
Complete the 'Patient Information' section, including the patient's name, date of birth, age, sex, and contact details. Make sure all information is legible to avoid delays.
Fill in the health plan details and member ID number. This information is essential for verifying coverage.
In the 'Referring Provider Name' section, enter your details along with any necessary contact information for follow-up.
Specify the requested facility and check off any relevant services needed. Provide a detailed diagnosis and include ICD-9 codes where applicable.
Finally, ensure you sign and date the form before submission to validate your request.

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lasalle prior authorization form

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