Get Illinicare Prior Authorization Form 2019

Completing the Illinicare Prior Authorization Form 2019 online requires attention to detail to ensure the authorization process goes smoothly. This guide provides clear step-by-step instructions to assist users in accurately filling out each section of the form, ensuring the necessary information is included for prompt processing.

Follow the steps to complete your Illinicare Prior Authorization Form 2019 online

1. Press the ‘Get Form’ button to access the Illinicare Prior Authorization Form 2019 and open it in your preferred document viewer.
2. In the Provider Information section, fill in the prescriber’s name, specialty, identification number, fax number, phone number, and the office contact name.
3. Complete the Member Information section by entering the member's name and date of birth. Be sure to include any known medication allergies.
4. In the Drug Information section, clearly state the drug name and strength, dosage form, dosage interval, quantity per day, and the diagnosis relevant to this request.
5. Indicate the expected length of therapy. This information helps clarify the duration for which the authorization is being requested.
6. Address the Medication History for this Diagnosis by indicating whether the member is currently treated with this medication and for how long. If the request is for continuation of a previous approval, indicate if there have been changes in strength, dosage, or quantity required per day.
7. If applicable, provide previous treatment details including drug names, doses, dates of therapy, and reasons for discontinuation.
8. In Section IV, provide the rationale for the request. This section requires appropriate clinical information to justify the medical necessity of the prescribed medication.
9. Finally, ensure the provider signs and dates the form before submission.
10. After completing the form, save changes and then download it. You can also choose to print or share the form as needed.

Complete your Illinicare Prior Authorization Form 2019 online today to ensure timely processing.