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Click ‘Get Form’ to open it in the editor.
Begin by entering the 'Request Date' at the top of the form. This is essential for tracking your submission.
In the 'Patient Information' section, fill in the patient's name, address, ID number, city, date of birth, and telephone number. If there are multiple members, list them on a separate sheet.
Next, provide details in the 'Service Provided Information' section. Include the fax number and date(s) of service.
Identify a contact person and specify the place of service. This information helps streamline communication regarding your request.
In the 'Explanation of Issue(s)' section, clearly articulate your concerns or reasons for requesting retro authorization. Be as detailed as possible to support your appeal.
Once completed, save a copy for your records. Send this form along with all necessary documentation to WellCare of Georgia via mail or fax as indicated.

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