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The form captures member information, requesting provider and servicing provider/facility identifiers, primary and additional procedure codes, diagnosis codes (ICD-10), start/end dates, and total units/visits/days. It includes a section for urgent requests, requiring physician signature for priority within 3 calendar days, and a checklist of required fields and submitted clinical documentation to avoid rejection or delayed determination.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/outpatient-authorization-form-complete-and-fax-to/288823/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/outpatient-authorization-form-complete-and-fax-to/288823.png","ImageObject",442,249,{"name":88,"@type":89},"Pentious","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-13","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required for an outpatient authorization request?","Question",{"text":108,"@type":109},"The form requires member details, requesting provider information, servicing provider/facility information, procedure codes (CPT/HCPCS) with modifiers, diagnosis code (ICD-10), start and end/admission and discharge dates, and total units/visits/days.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How do urgent requests work on this form?",{"text":113,"@type":109},"Urgent requests must be medically necessary and signed by the physician to receive priority. Urgent requests should be submitted within 3 calendar days to avoid complications.",{"name":115,"@type":106,"acceptedAnswer":116},"What happens if required fields are incomplete or clinical information is missing?",{"text":117,"@type":109},"Incomplete forms will be rejected, and missing supporting clinical information may result in delayed determination.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},288823,1789958783,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},1374404730887,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","OUTPATIENT AUTHORIZATION FORM  \nComplete and Fax to: 855-537-3447 Behavioral Health Requests/Medical Records:  \nFax 844-307-4442  \nRequest for additional units. Existing Authorization Units  \nUrgent 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.  \nURGENT REQUESTS MUST BE SIGNED BY THE PHYSICIAN TO RECEIVE PRIORITY  \n* INDICATES REQUIRED FIELD ~~ ~~  \n*Date of Birth  \nMEMBER 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*Primary Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS) (Modifier)  \nAdditional Procedure Code  \n(CPT/HCPCS)  \nAdditional Procedure Code  \n(CPT/HCPCS)  \n(Modifier)  \n(Modifier)  \n*Start Date OR Admission Date  \n(MMDDYYYY)  \nEnd Date OR Discharge Date  \n(MMDDYYYY)  \n*Diagnosis Code  \n(ICD-10)  \nTotal Units/Visits/Days  \n*1424*  \n\n| *OUTPATIENT SERVICE TYPE\u003Cbr>Check Box for Inpatient Elective Service |  | (Enter the Service type number in the boxes) |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n|  |  | Outpatient Services Outpatient Surgery Pain Management Radiation Therapy Sleep Study Transportation Transplant Evaluation Transplant Surgery | Behavioral Health\u003Cbr>510 BH Medical Management\u003Cbr>530 BH PHP | DME\u003Cbr>417 Rental\u003Cbr>120 Purchase | (Purchase Price) |\n| 422 Biopharmacy\u003Cbr>712 Cochlear Implants & Surgery\u003Cbr>299 Drug Testing\u003Cbr>922 Experimental and Investigational Services\u003Cbr>205 Genetic Testing & Counseling\u003Cbr>249 Home health\u003Cbr>390 Hospice Services\u003Cbr>290 Hyperbaric Oxygen Therapy\u003Cbr>395 Infertility Diagnosis or Treatment\u003Cbr>410 Observation\u003Cbr>997 Office Visit/Consult | 794\u003Cbr>171\u003Cbr>202\u003Cbr>650\u003Cbr>201\u003Cbr>724\u003Cbr>993\u003Cbr>209 |  |  |  |  |\n|  |  |  | 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>521 BH Psychological Testing |  |  |\n\n522 BH Psychiatric Evaluation  \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 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. 10 31 2019 ET-PAF-1424","cbCaipX4r8Sm7xUw","https://ap.wps.com/l/cbCaipX4r8Sm7xUw","pdf",811121,"English","# Outpatient Authorization Form\n## Member, Provider, and Facility Information\n## Authorization Request Details\n## Outpatient Service Type Selection\n## Required Documentation, Disclaimers, and Confidentiality","[{\"question\":\"What information is required for an outpatient authorization request?\",\"answer\":\"The form requires member details, requesting provider information, servicing provider/facility information, procedure codes (CPT/HCPCS) with modifiers, diagnosis code (ICD-10), start and end/admission and discharge dates, and total units/visits/days.\"},{\"question\":\"How do urgent requests work on this form?\",\"answer\":\"Urgent requests must be medically necessary and signed by the physician to receive priority. Urgent requests should be submitted within 3 calendar days to avoid complications.\"},{\"question\":\"What happens if required fields are incomplete or clinical information is missing?\",\"answer\":\"Incomplete forms will be rejected, and missing supporting clinical information may result in delayed determination.\"}]","OUTPATIENT AUTHORIZATION FORM - Complete and Fax to | PDF",1789634022]