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WARF - Outpatient Request Form

This application does not allow for attachments. If you have attachments to send with your request, please log in and use Care Affiliate to submit your authorization or referral request.

Note: If you are unsure what to select in the "Request Profile" section, please use the Request Profile Guide to help.

We also offer a step-by-step guide to using WARF.

To improve usability, changes to this tool are coming soon.

= Required Field

Type

SSN Patient DBN

Sponsor SSN

Patient's First Name

Patient's Last Name

Date Of Birth

Street Address

Postal Code

City

State

Phone Number

Requesting Provider Details

Click here for Provider Lookup

Contact Name

Contact Phone Number

Provider Name

NPI

Tax ID

Phone Number

Fax Number

Street Address

Postal Code

City

State

Specialty

Is the servicing provider the same as the requesting provider?

Priority and Diagnosis

Event Classification

Clinical Documentation Required:

Request Profile

Request Type

Specialty Referral Outpatient Authorizations Outpatient Behavioral Health

WARF Tool Request Profile Guide

Servicing Provider Details

Click here for Provider Lookup

Provider Name

NPI

Tax ID

Phone Number

Fax Number

Street Address

Postal Code

City

State

Specialty

<div class="col-xs-12 p0 descriptionMainClone">
         <div class="col-md-8 col-sm-10 col-xs-9 p0">
             <div class="col-sm-6 col-xs-12 dianosCode">
                 <div class="form-group ">
                     <label class="required">Diagnosis Code 
                     
                     <span class="glyphicon glyphicon-question-sign ml5" data-toggle="tooltip" data-placement="bottom" title="Enter ONLY a valid ICD10 code"></span></label>
                     <input type="text" data-rule-diagonis="true" name="diagnosisCode" data-msg-required="Diagnosis Code is required" data-rule-required="true" id="diagnosisCode" class="form-control diagnosisCodeSSN" onchange="getDiagnosisDescription(this)" />
                 </div>
             </div>
             <div class="col-sm-6 col-xs-12 dianosCode">
                 <div class="form-group">
                     <label>Description 
                     </label>
                     <input type="text" name="diagnosisDescription" id="diagnosisDescription" class="form-control diagnosisDescriptionSSN" readonly/>
                 </div>
             </div>
         </div>
         <div class="col-sm-2 col-xs-3 p0 mt20">
             <a href="javascript:void(0)" class="addDescription addDescription{0}"><div class="add-circle pull-left"></div></a>
             <a href="javascript:void(0)" class="deleteDescription"><div class="minus-circle pull-left "></div></a>
         </div>
     </div>

Specialty

Type

Provider Name

NPI

Tax ID

Specialty

City

State

Postal Code

Name	NPI	TIN	Group Name	Street Address	City	State	Postal Code	Network Status