Get Simply Healthcare Prior Authorization Form 2020-2025

The Simply Healthcare Prior Authorization Form is essential for obtaining necessary authorizations for . This guide provides clear, step-by-step instructions to help users complete the form online efficiently and accurately.

Follow the steps to successfully complete the Prior Authorization Form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member's Medicaid ID number, followed by their date of birth in MM/DD/YYYY format. Ensure all details are accurate.
3. Provide the full name of the member, along with the prescriber’s full name, license number, and contact information, including phone and fax numbers.
4. Indicate the quantity of vials requested and the prescribed dosage. The usual dosage is to inject 15 mg/kg IM once monthly.
5. Input the start date for the treatment and specify any refills required. Include the member's birth weight and current weight.
6. Confirm the gestational age of the member and provide necessary details related to any clinical criteria, such as having cystic fibrosis or congenital heart disease, along with appropriate ICD-9 codes.
7. Ensure all relevant supporting information is attached, including a copy of the original prescription. The prescriber must sign and date the form.
8. After completing the form, you can save the changes. Options to download, print, or share the document will be available for your convenience.

Complete your Simply Healthcare Prior Authorization Form online today to ensure timely processing.