[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283810-105":53,"doc-detail-283810-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","outpatient-authorization-request-form-wellcare","Outpatient Authorization Request Form - Wellcare","","Outpatient Authorization Request Form from Wellcare for submitting clinical and administrative information needed to request prior authorization for outpatient services. The form specifies required clinical documentation such as current physician orders, physician notes, and recent diagnostics, and it requires notification for any date-of-service changes. It supports expedited requests by phone when delays may jeopardize the member’s life, health, or ability to regain maximum function, and it includes structured sections for requestor, member, provider details, diagnosis and procedure codes, service type, place of service, and anticipated service date, with fax routing by state.",{"@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-request-form-wellcare/283810/",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-request-form-wellcare/283810.png","ImageObject",442,249,{"name":88,"@type":89},"Asher","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-11-03","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required to complete the Outpatient Authorization Request Form?","Question",{"text":108,"@type":109},"The form requires clinical information and supporting documentation including current physician orders, physician notes, and recent diagnostics.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How do expedited requests work?",{"text":113,"@type":109},"Expedited requests can be submitted by calling 1-855-538-0454 when the standard decision time could seriously jeopardize the member’s life and/or health or ability to regain maximum function.",{"name":115,"@type":106,"acceptedAnswer":116},"Where should the completed form be sent?",{"text":117,"@type":109},"Send the completed form by fax to the appropriate Medicare fax line listed by state, shown in the fax submission section at the bottom of the form.","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},283810,1790219031,{"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":20,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"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":9},687197207639,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","Want faster service? Use our Provider [Portal at](Portal at provider.wellcare.com)[ provider.wellcare.com](Portal at provider.wellcare.com). \nOutpatient 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 appropriate number at bottom of form. \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| Servicing Provider or Facility (please print) | | | |\n| Wellcare ID: | NPI/Tax ID* : | | |\n| Provider/Facility Name* : | Fax* : | Phone: | |\n| Address: | City: | State: | ZIP Code: |\n| Treating 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 5715955_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| □ Dialysis □ Office Visit/Procedure □ Radiation Therapy □ MRI □ Sleep Study □ X-Rays □ CT Scan\u003Cbr>□ Other (please specify): | | | | | |\n| Place of Service: (check one): | □ Telehealth (02) □ Office (11)\u003Cbr>□ Dialysis Center (65) □ Lab (81) | | | □ Outpatient Hospital (22) | |\n| Anticipated Service 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 Please fax completed form to: \n\n| Medicare Fax Lines | |\n| --- | --- |\n| Connecticut: 1-866-455-6529 | Kentucky: 1-888-361-5684 |\n| Florida Medicare only: 1-877-892-8216 | New Jersey: 1-877-892-8221 |\n| Georgia Medicare only: 1-877-892-8213 | New York: 1-877-892-8214 |\n| Florida/Georgia Dual: 1-877-277-1820 | Texas: 1-877-894-2034 |\n| Illinois: 1-877-899-2044 | All others: 1-888-361-5684 |\n\n[wellcare.com](wellcare.com)","cbCaikZkmCKlk8wK","https://ap.wps.com/l/cbCaikZkmCKlk8wK","pdf",96460,"English","# Outpatient Authorization Request Form\n## Requirements and Expedited Requests\n## Requester and Member Information\n## Provider Information\n## Diagnosis and Requested Services\n## Procedure Codes and Place of Service\n## Fax Submission Lines by State","[{\"question\":\"What information is required to complete the Outpatient Authorization Request Form?\",\"answer\":\"The form requires clinical information and supporting documentation including current physician orders, physician notes, and recent diagnostics.\"},{\"question\":\"How do expedited requests work?\",\"answer\":\"Expedited requests can be submitted by calling 1-855-538-0454 when the standard decision time could seriously jeopardize the member’s life and/or health or ability to regain maximum function.\"},{\"question\":\"Where should the completed form be sent?\",\"answer\":\"Send the completed form by fax to the appropriate Medicare fax line listed by state, shown in the fax submission section at the bottom of the form.\"}]","Outpatient Authorization Request Form - Wellcare | PDF",1789620199]