[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-288824-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-288824-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","inpatient-authorization-form-read-online-free","INPATIENT AUTHORIZATION FORM - read online free","","Inpatient authorization form for medical service approval, requiring completion of member, requesting provider, and servicing provider/facility details. It supports standard and urgent requests, with urgent submissions certified as medically necessary and requiring physician signature for priority processing within specified timelines. The form collects procedure codes (CPT/HCPCS) with modifiers, admission/start and discharge dates, diagnosis codes (ICD-10), and inpatient service type selection. It states that incomplete forms or missing clinical documents are rejected or may delay determination, and includes confidentiality and payment-disclaimer notices.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/inpatient-authorization-form-read-online-free/288824/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/inpatient-authorization-form-read-online-free/288824.png","ImageObject",442,249,{"name":42,"@type":43},"Stanley","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-09","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":30},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What are the standard vs. urgent request processing timelines?","Question",{"text":62,"@type":63},"Standard requests are determined within 14 calendar days after receiving all necessary information. Urgent requests are certified as medically necessary to be treated within 72 hours to avoid complications and severe pain.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"Who must sign urgent requests to receive priority?",{"text":67,"@type":63},"Urgent requests must be signed by the physician to receive priority.",{"name":69,"@type":60,"acceptedAnswer":70},"What happens if the form is incomplete or clinical information is missing?",{"text":71,"@type":63},"Incomplete forms will be rejected. Lack of supporting clinical information may result in delayed determination.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},288824,1790182204,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":135,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":4},2336477405376,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","INPATIENT AUTHORIZATION FORM  \nComplete and Fax to: 1-844-560-0799  \nStandard requests-Determination within 14 calendar days of receiving all necessary information.  \nUrgent requests- I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 72 hours to avoid complications and unnecessary suffering or severe pain.  \nX  \nURGENT REQUESTS MUST BE SIGNED BY THE PHYSICIAN TO RECEIVE PRIORITY  \n* Indicates Required Field ~~  ~~MEMBER INFORMATION *Date of Birth  \n*Medicaid/Member ID Last Name, First (MMDDYYYY)  \nREQUESTING PROVIDER INFORMATION  \n*Requesting NPI *Requesting TIN Requesting Provider Contact Name  \nRequesting Provider Name Phone *Fax  \nSERVICING PROVIDER / FACILITY INFORMATION  \n~~ ~~ Same as Requesting Provider  \n*Servicing NPI *Servicing TIN Servicing Provider Contact Name  \nServicing Provider/Facility Name Phone Fax  \nAUTHORIZATION REQUEST  \n*Primary Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \n*Start Date OR Admission Date  \n(MMDDYYYY)  \nDischarge Date (if applicable) otherwise  \nLength of Stay will be based on Medical Necessity  \n(MMDDYYYY)  \n*Diagnosis Code  \n■  \n(ICD-10)  \nAdditional Diagnosis Code  \n■  \n(ICD-10)  \n\n| *INPATIENT SERVICE TYPE (Enter the Service type number in the boxes) |  |  |\n| --- | --- | --- |\n| Delivery\u003Cbr>779 C-Section Delivery\u003Cbr>720 Vaginal Delivery\u003Cbr>Rehab\u003Cbr>427 Rehab\u003Cbr>Transplant\u003Cbr>477 Transplant Admission | Miscellaneous\u003Cbr>121 Long Term Acute Care\u003Cbr>970 Medical\u003Cbr>414 Premature/False Labor\u003Cbr>402 Skilled Nursing Facility\u003Cbr>411 Surgical\u003Cbr>490 Boarder Baby\u003Cbr>300 Neonate | Behavioral Health\u003Cbr>528 BH Chemical Substance Abuse\u003Cbr>529 BH Psychiatric Admission\u003Cbr>531 BH Eating Disorders\u003Cbr>532 BH Crisis Stabilization Unit\u003Cbr>535 BH Residential Treatment-Substance Use\u003Cbr>536 BH Residential Treatment-Mental Health |\n\nALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED.  \nCOPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION.  \nDisclaimer: An authorization is not a guarantee of payment. Member must be eligible at the time services are rendered. Services must be a covered Health Plan Benefit and medically necessary with prior authorization as per Plan policy and procedures.  \nConfidentiality: The information contained in this transmission is confidential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not Rev. 03 26 2019  \nthe intended recipient any use, distribution, or copying is strictly prohibited. If you have received this facsimile in error, please notify us immediately and destroy this document. ES-PAF-1418  \nAMB19-SC-P-03262019-1","cbCaii1Ba3oJprHE","https://ap.wps.com/l/cbCaii1Ba3oJprHE","pdf",415680,8,"English","# Member Information\n## Requesting Provider Information\n## Servicing Provider / Facility Information\n# Authorization Request\n## Procedure Codes and Dates\n## Diagnosis Codes\n# Inpatient Service Type\n# Required Attachments and Disclaimers","[{\"question\":\"What are the standard vs. urgent request processing timelines?\",\"answer\":\"Standard requests are determined within 14 calendar days after receiving all necessary information. Urgent requests are certified as medically necessary to be treated within 72 hours to avoid complications and severe pain.\"},{\"question\":\"Who must sign urgent requests to receive priority?\",\"answer\":\"Urgent requests must be signed by the physician to receive priority.\"},{\"question\":\"What happens if the form is incomplete or clinical information is missing?\",\"answer\":\"Incomplete forms will be rejected. Lack of supporting clinical information may result in delayed determination.\"}]","INPATIENT AUTHORIZATION FORM - read online free | PDF",1789634026]