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New Authorization Treatment/Service Request Forms – MLTC (Managed Long Term Care)
1/9/2020 • Posted by Provider Relations

Fidelis Care has created two new authorization treatment/service request forms (Audiology and Podiatry) for our members enrolled in our managed long term care product, Fidelis Care at Home.  In addition, updates have been made to the existing Durable Medical Equipment (DME) form.

These forms can be found on our website fideliscare.org by accessing Providers > Manuals and Forms > Forms and Applications > in a new section titled:
Treatment/Service Request Forms – MLTC (Managed Long Term Care)

Durable Medical Equipment Request Form
Hearing Aid Services and Products Request Form
Podiatry Services Request Form

Completed authorization treatment/service request forms must be faxed to fax number:  (716) 803-8727.

If you have any questions, please contact the Fidelis Care Provider Call Center at (888) 343-3547.

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