Get the free NM-PAF-5846-Outpatient Medicaid Authorization Form. Outpatient Medicaid Authorizatio...

OUTPATIENT MEDICAID AUTHORIZATION FORM Request for additional units. Existing AuthorizationStandard Requests: Fax 8448054593 Transplant Requests: Fax 8339743113UnitsStandard Requests Determination

How to fill out nm-paf-5846-outpatient medicaid authorization form

How to fill out nm-paf-5846-outpatient medicaid authorization form

1. Start by obtaining the NM-PAF-5846 form. It can be downloaded from the official Medicaid website or obtained from your healthcare provider.
2. Fill out the following information at the top of the form: patient's name, address, phone number, and Medicaid ID.
3. Provide demographic information, including the patient's date of birth, social security number, and gender.
4. Indicate the type of service being requested by checking the appropriate boxes. This could include outpatient medical, dental, behavioral health, or other specialized services.
5. Specify the requested dates and duration of the requested services.
6. If applicable, provide details about the healthcare provider who will be delivering the services, including their name, address, phone number, and national provider identifier (NPI) number.
7. Complete the section for the primary diagnosis, including the ICD-10 code.
8. If there are any additional diagnoses or medical conditions relevant to the requested services, provide this information in the corresponding section.
9. If there are any supporting documents that need to be attached to the authorization request, ensure they are properly attached.
10. Review the completed form for accuracy and completeness before submitting it.
11. Sign and date the form.
12. Submit the filled out NM-PAF-5846 form to the appropriate Medicaid office or your healthcare provider.

Who needs nm-paf-5846-outpatient medicaid authorization form?

1. The NM-PAF-5846 Outpatient Medicaid Authorization form is needed by individuals who are covered by Medicaid and require authorization for outpatient medical services. This could include patients who need to access specialized medical care, dental treatments, behavioral health services, or other types of outpatient care. The form is typically filled out by the patient or their healthcare provider and submitted to the Medicaid office for review and approval.

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What is nm-paf-5846-outpatient medicaid authorization form?

The nm-paf-5846-outpatient medicaid authorization form is a form used to request authorization for outpatient Medicaid services.

Who is required to file nm-paf-5846-outpatient medicaid authorization form?

Healthcare providers and facilities who wish to provide outpatient services to Medicaid patients are required to file the nm-paf-5846-outpatient medicaid authorization form.

How to fill out nm-paf-5846-outpatient medicaid authorization form?

To fill out the nm-paf-5846-outpatient medicaid authorization form, providers need to provide patient information, service details, and any other requested information accurately.

What is the purpose of nm-paf-5846-outpatient medicaid authorization form?

The purpose of the nm-paf-5846-outpatient medicaid authorization form is to obtain approval from Medicaid for outpatient services provided to eligible patients.

What information must be reported on nm-paf-5846-outpatient medicaid authorization form?

Providers need to report patient demographics, diagnosis, treatment plan, provider information, and any other relevant details on the nm-paf-5846-outpatient medicaid authorization form.