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The document provides fax-only instructions, including where to send requests for standard providers and where to fax requests involving a CareFirst employee. It collects requester and patient information, service dates, place of service, physician and facility details, diagnosis and procedure codes (ICD-10 and CPT-4), and referral information. 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In most cases, you should receive a response via fax or telephone within two business days. Please fax only the authorization request form to (410) 781-7661. If requesting an authorization for a CareFirst employee, fax the request to (410) 505-2840. Please submit this completed form only at this time. Additional clinical information will be requested if needed.  \nRequest from: Doctor’s office Hospital Please fax authorization request to (410) 781-7661.  \n\n| Name: | Date: |\n| --- | --- |\n| Telephone Number: | Fax Number: |\n| Participating Provider Number, NPI or Tax ID\\# (under which you will bill claims): |  |\n\n\n| Patient’s Name: |  | Date of Birth: |  |\n| --- | --- | --- | --- |\n| Patient’s Identification Number: |  | Group Number: |  |\n| Address: |  | Telephone Number: |  |\n| City: |  | State: | Zip Code: |\n|  |  |  |  |\n| Date(s) of Service or Admit Date(s): |  |  |  |\n| Place of Service (check one):\u003Cbr>Inpatient Facility Outpatient Facility Emergency Room Admit Physician’s Office |  |  |  |\n| Admitting/Treating Physician’s Name: |  | Telephone Number: |  |\n| Physician’s Address: |  |  |  |\n| Diagnosis Code(s) (ICD-10): |  |  |  |\n| Procedure Code(s) (CPT-4): |  |  |  |\n| Hospital/Facility: |  | Telephone Number: |  |\n| Hospital/Facility Address: |  |  |  |\n| Hospital/Facility Telephone Number: |  |  |  |\n| Referral Number (if applicable): | Referral Issue Date: |  |  |\n|  |  |  |  |\n| AUTHORIZATION NUMBER (FOR INTERNAL OFFICE USE ONLY) |  |  |  |\n| Associate Name: | Completed by: |  |  |\n| Date: | Time: |  |  |\n| Comments: |  |  |  |\n\nCUT9233-1E (9/15)  \nCareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc . and Group Hospitalization and Medical Services, Inc .  \nCareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc . are independent licensees of the Blue Cross and Blue Shield Association.  \n® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc .","cbCaipDsYQ5LDwgQ","https://ap.wps.com/l/cbCaipDsYQ5LDwgQ","pdf",113946,"English","# Instructions\n# Requester Information\n# Patient and Service Details\n# Provider, Diagnosis, and Procedure Codes\n# Authorization Number and Internal Use","[{\"question\":\"How should the authorization request be submitted?\",\"answer\":\"Fax the completed authorization request form only to the number specified in the instructions. Response timing is typically within two business days via fax or telephone.\"},{\"question\":\"What information is required about the patient?\",\"answer\":\"The form requests patient’s name, identification number, date of birth, group number, address, and contact details, along with date(s) of service or admit date(s).\"},{\"question\":\"Which clinical coding fields are included on the form?\",\"answer\":\"It includes diagnosis code(s) using ICD-10 and procedure code(s) using CPT-4, plus place of service and admitting/treating physician information.\"}]","CareFirst Precertification Request for Authorization of Services Form | PDF",1789633517]