Mpi authorization form 2026

1. Click ‘Get Form’ to open the mpi authorization form in the editor.
2. Begin by filling out the 'Provider Data' section. Enter the treating physician's name, National Provider ID Number, today's date, and Tax ID Number. Ensure all contact details such as address, city, state, email, phone, and zip code are accurately provided.
3. In the 'Authorization Data' section, input the patient's name and date of birth. Include the participant’s ID number and their name. Specify the number of units requested for visits or services and provide anatomic site details if applicable.
4. Next, indicate the date when the service is to be performed. Fill in diagnosis and ICD-10 codes along with procedure requested and CPT/HCPCS codes.
5. Attach any necessary documentation that supports your request in the designated area. This may include letters of medical necessity or clinical quality photos.

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