OUTPATIENT AUTHORIZATION FORM - Complete and Fax to 855-537-3447

Sep 17, 2026

Upload by Aurora

Outpatient Authorization Form for requesting prior authorization for outpatient services. Includes fields for member information, Medicaid/Member ID, requesting provider details (NPI, TIN, contact), servicing provider/facility information, and the authorization request with procedure codes (CPT/HCPCS), modifiers, start/admission and end/discharge dates, diagnosis codes, and total units/visits/days. Provides an urgent request certification requiring physician signature within 3 calendar days, and lists required supporting clinical documentation. Includes confidentiality and payment-not-guaranteed disclaimer.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Member Information

Requesting Provider Information

Servicing Provider/Facility Information

Authorization Request

Outpatient Service Type

Required Documentation and Disclaimers

OUTPATIENT AUTHORIZATION FORM Complete and Fax to: 855-537-3447 Behavioral Health Requests/Medical Records: Fax 844-307-4442 Transplant: Fax 833-589-1240 Request for additional units. Existing Authorization Urgent requests- I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 3 calendar days to avoid complications and unnecessary suffering or severe pain. URGENT REQUESTS MUST BE SIGNED BY THE PHYSICIAN TO RECEIVE PRIORITY * INDICATES REQUIRED FIELD ~~ ~~ *Date of Birth MEMBER INFORMATION * Medicaid/Member ID Last Name, First (MMDDYYYY) REQUESTING PROVIDER INFORMATION *1424* *Requesting NPI *Requesting TIN Requesting Provider Contact Name Requesting Provider Name Phone *Fax SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Provider *Servicing NPI *Servicing TIN Servicing Provider Contact Name Servicing Provider/Facility Name Phone Fax AUTHORIZATION REQUEST *Primary Procedure Code Additional Procedure Code *Start Date OR Admission Date *Diagnosis Code (CPT/HCPCS) (Modifier) (CPT/HCPCS) (Modifier) (MMDDYYYY) (ICD-10) Additional Procedure Code Additional Procedure Code End Date OR Discharge Date Total Units/Visits/Days (CPT/HCPCS) (Modifier) (CPT/HCPCS) (Modifier) *OUTPATIENT SERVICE TYPE (Enter the Service type number in the boxes) Check Box for Inpatient Elective Service Behavioral Health DME 422 Biopharmacy 794 Outpatient Services 515300 BBHH MePHical Management 417120 RentaPurchse 712 Cochlear Implants & Surgery 171 Outpatient Surgery (Purchase Price) 292920925 DEGrxupegenreTiemtisectnTingtaeslt&inIngve&stCigaoutnionselSngervices 262050201 PRSiiMatpaSinontuemherentapy 555111256 BBBHHH CEImcetnmrosiucvnoeitynvOBuutlaspsaievteiereTicpeesyrapy 249 Home health 724 Transportation 518 BH Mental Health/Chemical Dependency Observation 390 Hospice Services 993 Transplant Evaluation 519 BH Outpatient Therapy 290 Hyperbaric Oxygen Therapy 209 Transplant Surgery 520 BH Professional Fees 395 Infertility Diagnosis or Treatment 522 BH Psychiatric Evaluation 410 Observation 521 BH Psychological Testing 997 Office Visit/Consult ALL REQUIRED FIELDS MUST BE FILLED IN AS INCOMPLETE FORMS WILL BE REJECTED. COPIES OF ALL SUPPORTING CLINICAL INFORMATION ARE REQUIRED. LACK OF CLINICAL INFORMATION MAY RESULT IN DELAYED DETERMINATION. Disclaimer: 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. Confidentiality: 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 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. Rev. 12 17 2020 ET-PAF-1424

FAQs

What information is required for the member section?

The form requires the member date of birth and the Medicaid/Member ID along with the member’s last name and first name.

How should urgent requests be submitted?

Urgent requests must be certified as medically necessary and require a physician signature to receive priority within 3 calendar days to avoid complications.

What happens if required fields or supporting clinical information are missing?

Incomplete forms will be rejected, and lack of clinical information may result in delayed determination.

Sep 17, 2026

Upload by Aurora