Get 800 551 5258

Filling out the 800 551 5258 form online is a straightforward process that can streamline your prior authorization requests. This guide provides clear, step-by-step instructions to ensure that you can complete the form accurately and efficiently.

Follow the steps to effectively fill out the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor for easy access.
2. Enter the patient information in the required fields such as name, address, and date of birth. Make sure to provide accurate contact details, including home phone and relationship to the patient.
3. Fill in the insurance information by specifying primary and secondary insurance details, including subscriber names and identification numbers. This ensures proper processing of the authorization request.
4. Complete the prescriber information section, providing the prescriber’s name, contact details, and DEA number. This information is crucial for the approval process.
5. In the diagnosis and clinical information section, include the primary ICD-9 code, along with any additional medical justification for the requested therapy. Attach any necessary documentation if needed.
6. Specify the prescription information, such as prescription type (new start or continued treatment), medication requested, dosage, quantity, and expected duration of therapy.
7. Ensure that the prescriber’s original signature is included in the designated area, as the form cannot be processed without it.
8. Review all entered information for accuracy. Once completed, you can save changes, download, print, or share the form as necessary.

Start completing the 800 551 5258 form online to ensure your prior authorization request is processed efficiently.