[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-288082-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-288082-en":127},{"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":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","outpatient-authorization-form-complete-and-fax-request","OUTPATIENT AUTHORIZATION FORM - Complete and Fax Request","","Outpatient Authorization Form for requesting prior authorization via fax, including standard and urgent request workflows. The form requires physician-signed urgent requests submitted within 72 hours for medically necessary, non-life-threatening injuries, illnesses, or conditions. It captures member identifiers, requesting provider and servicing provider/facility details, authorization request identifiers (e.g., procedure codes and dates), diagnosis and total units, and a structured outpatient service type selection. It specifies required fields, supporting clinical documentation, and includes payment authorization disclaimers and confidentiality notices, with revision information dated 07 16 2025.",{"@graph":14,"@context":73},[15,34,56],{"@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/outpatient-authorization-form-complete-and-fax-request/288082/",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/outpatient-authorization-form-complete-and-fax-request/288082.png","ImageObject",442,249,{"name":42,"@type":43},"Maeve","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-24","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",7,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"How are standard and urgent requests handled?","Question",{"text":63,"@type":64},"Standard requests require determination within 2 business days after receiving all necessary information. Urgent requests must be medically necessary and require physician signature to receive priority.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What information must be completed on the form to avoid rejection?",{"text":68,"@type":64},"All required fields must be filled in, as incomplete forms are rejected. Supporting clinical information must also be included, as missing details may delay determination.",{"name":70,"@type":61,"acceptedAnswer":71},"What does the form say about payment authorization and confidentiality?",{"text":72,"@type":64},"Authorization is not a guarantee of payment, and services must be covered and medically necessary per plan policy. The transmission is confidential and may be protected under HIPAA; misuse is prohibited and errors should be reported immediately.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},288082,1790176100,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"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},5909877438554,"https://ap-avatar.wpscdn.com/avatar/5600025385ad2bf12a7?_k=1778553567797529272","OUTPATIENT AUTHORIZATION FORM  \nComplete and Fax to: 1-844-827-4948  \nTransplant Fax to: 1-833-590-1583 Buy & Bill Drugs Fax to: 1-833-893-1482  \nStandard requests-Determination within 2 business 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 sufering or severe pain.  \nURGENT REQUESTS MUST BE SIGNED BY THE PHYSICIAN TO RECEIVE PRIORITY  \n* INDICATES REQUIRED FIELD  *Date of Birth  MEMBER INFORMATION   \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*5867*  \n*Primary Procedure Code  \n(CPT/HCPCS) (Modifer)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifer)  \nAdditional Procedure Code  \n(CPT/HCPCS)  \nAdditional Procedure Code  \n(CPT/HCPCS)  \n*Start Date OR Admission Date  \n(MMDDYYYY)  \nEnd Date OR Discharge Date  \n(MMDDYYYY)  \n*Diagnosis Code  \nTotal Units/Visits/Days  \n| *OUTPATIENT SERVICE TYPE (Enter the Service type number in the boxes)  |  |  |  |\n| --- | --- | --- | --- |\n| 422 Biopharmacy 794 Outpatient Services\u003Cbr>712 Cochlear Implants & Surgery 171 Outpatient Surgery\u003Cbr>299 Drug Testing 202 Pain Management\u003Cbr>922 Experimental and Investigational 650 Radiation Therapy Services 201 Sleep Study\u003Cbr>205 Genetic Testing & Counseling 993 Transplant Evaluation\u003Cbr>249 Home Health 209 Transplant Surgery\u003Cbr>390 Hospice Services 724 Transportation\u003Cbr>290 Hyperbaric Oxygen Therapy |  |  | Behavioral Health\u003Cbr>512 BH Community Based Services\u003Cbr>515 BH Electroconvulsive Therapy\u003Cbr>516 BH Intensive Outpatient Therapy\u003Cbr>518 BH Mental Health /Chemical Dependency Observation\u003Cbr>519 BH Outpatient Therapy\u003Cbr>520 BH Professional Fees\u003Cbr>522 BH Psychiatric Evaluation\u003Cbr>DME\u003Cbr>417 Rental\u003Cbr>120 Purchase\u003Cbr>\u003Cbr>(Purchase Price) |\n| 709 | Genetic Testing-For Genetic Testing please include GTU: | |  |\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 Beneft and medically necessary with prior authorization as per Plan policy and procedures.  \nConfdentiality: The information contained in this transmission is confdential and may be protected under the Health Insurance Portability and Accountability Act of 1996. If you are not the 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.  \nRev. 07 16 2025 EP-PAF-5867","cbCaikasWmvJP7As","https://ap.wps.com/l/cbCaikasWmvJP7As","pdf",775401,"English","# Member Information\n# Requesting Provider Information\n# Servicing Provider / Facility Information\n# Authorization Request\n# Outpatient Service Type Selection\n# Required Documentation and Notices","[{\"question\":\"How are standard and urgent requests handled?\",\"answer\":\"Standard requests require determination within 2 business days after receiving all necessary information. Urgent requests must be medically necessary and require physician signature to receive priority.\"},{\"question\":\"What information must be completed on the form to avoid rejection?\",\"answer\":\"All required fields must be filled in, as incomplete forms are rejected. Supporting clinical information must also be included, as missing details may delay determination.\"},{\"question\":\"What does the form say about payment authorization and confidentiality?\",\"answer\":\"Authorization is not a guarantee of payment, and services must be covered and medically necessary per plan policy. The transmission is confidential and may be protected under HIPAA; misuse is prohibited and errors should be reported immediately.\"}]","OUTPATIENT AUTHORIZATION FORM - Complete and Fax Request | PDF",1789633089]