up a member, Patient Detail information defaults Click Next to continue Requesting Provider Information data defaults Note: Enter in the fax # where official Step communication 2 about this Prior authorization should be sent Click Next to continue Step Service Provider 3 Information defaults Continued on next page Enter a Service Request Facility information populates the fields from the search Step selection 31 Enter a Servicing NPI Facility information populates the fields from the search Step selection 31 Select an Attending Physician (Inpatient Only) Facility information populates the fields
up a member, Patient Detail information defaults Click Next to continue Step 2 Requesting Provider Information data defaults Note: Enter in the fax # where official communication about this Prior authorization should be sent Click Next to continue Step 3 Service Provider Information defaults Continued on next page Enter a Service Request Step 31 Facility information populates the fields from the search selection Enter a Servicing NPI Step 31 Facility information populates the fields from the search selection Select an Attending Physician (Inpatient Only) Facility information populates the fields