Triwest prior authorization form 2021-2026

1. Click ‘Get Form’ to open the triwest prior authorization form 2021 in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the Patient DoD/Benefits # or Sponsor SSN, Last Name, First Name, Date of Birth, Home Address, City, State, Phone Number, and Zip Code.
3. Next, complete the 'Referral Source Information' section. Provide your name as the person completing the form along with your phone number and the patient's primary physician's details including their phone and fax numbers.
4. In the 'Specialist(s) Involved in Care' section, list any specialists involved in the patient's care by providing their names, specialties, phone numbers, and fax numbers.
5. Indicate if the patient is currently receiving any services from the provided options. Select all that apply.
6. Answer whether the beneficiary or primary caregiver has been informed about this CM referral submission.
7. If applicable, confirm if consent for Mental Health/Substance Abuse services has been obtained for Behavioral Health referrals.
8. Finally, provide a detailed reason for referral before submitting your completed form via fax to 1-866-269-5758.

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