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Use our Provider [Portal at](Portal at provider.wellcare.com)[ provider.wellcare.com](Portal at provider.wellcare.com).  \nInpatient Authorization Request Form  \n*Indicates a required field  \nRequirements: Clinical information and supporting documentation should consist of current physician orders, notes, and recent diagnostics. Notification is required for any date-of-service change.  \nExpedited Requests: If the standard time to make a determination could seriously jeopardize the life and/or health of the member or the member's ability to regain maximum function, please call 1-855-538-0454.  \n Please fax completed form to 1-855-776-9464.  \n\n| Requestor Name* : | Fax* : | Phone* : |\n| --- | --- | --- |\n\n\n| Member Information (please print) |  |  |  |\n| --- | --- | --- | --- |\n| Wellcare ID* : | Medicaid/Medicare ID: |  |  |\n| Last Name* : | First Name, MI* : | Date of Birth* :/ / |  |\n| Requesting Provider (please print) |  |  |  |\n| Wellcare ID: | NPI/Tax ID* : |  |  |\n| Provider Name* : | Fax* : | Phone: |  |\n| Address: | City: | State: | ZIP Code: |\n| Facility (please print) |  |  |  |\n| Wellcare ID: | NPI/Tax ID* : |  |  |\n| Provider/Facility Name* : | Fax* : | Phone: |  |\n| Address: | City: | State: | ZIP Code: |\n| Attending Provider (please print) |  |  |  |\n| Wellcare ID: | NPI/Tax ID* : |  |  |\n| Provider/Facility Name* : | Fax* : | Phone: |  |\n| Address: | City: | State: | ZIP Code: |\n\n(continued)  \n©Wellcare 2026 5716601_NA6PCARFRME  \nInternal Approved 02032026  \n\n| Diagnosis Codes* |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| ICD-10: |  | ICD-10: |  |  | ICD-10: | ICD-10: |\n| Requested Services (please choose only one) |  |  |  |  |  |  |\n| □ Observation\u003Cbr>□ Waitlist | □ Inpatient Admission\u003Cbr>□ ICF |  |  | □ LTACH □ SNF/Sub-Acute Rehab □ Inpatient Rehab\u003Cbr>□ Other (please specify):   |  |  |\n| Place of Service: (check one): |  | □ ALF (13) □ Observation Hospital (22) □ Inpatient (21)\u003Cbr>□ SNF (31) □ Nursing Facility (32) |  |  |  |  |\n| Date of Admission* : / |  | / |  |  | Is this a Level of Care Change (OBS to INP)?: □ Yes □ No Observation Admit Date: / / |  |\n| Procedure Code(s)* |  |  | Description |  |  |  |\n| CPT Code: |  |  |  |  |  |  |\n| CPT Code: |  |  |  |  |  |  |\n| CPT Code: |  |  |  |  |  |  |\n| CPT Code: |  |  |  |  |  |  |\n| CPT Code: |  |  |  |  |  |  |\n| CPT Code: |  |  |  |  |  |  |\n\n[wellcare.com](wellcare.com)","cbCaiuM3HaKfm1w2","https://ap.wps.com/l/cbCaiuM3HaKfm1w2","pdf",93931,"English","# Inpatient Authorization Request Form\n## Submission requirements and expedited requests\n## Requestor information\n## Member and provider details\n## Diagnosis, services, place of service, and procedure codes","[{\"question\":\"What information is required to support an inpatient authorization request?\",\"answer\":\"Clinical information must include current physician orders, notes, and recent diagnostics. Supporting documentation should match these requirements for the request.\"},{\"question\":\"When should a provider submit an expedited request?\",\"answer\":\"Expedited requests are appropriate when the standard determination time could seriously jeopardize the member’s life and/or health or their ability to regain maximum function.\"},{\"question\":\"How should completed requests be submitted?\",\"answer\":\"Completed forms are submitted by fax to the provided fax number. The form also includes instructions for faster service via the provider portal.\"}]","NA Care Provider Inpatient Authorization Request Form - 2026 | PDF",1789620200]