Get Wisconsin Admin Code 10710 Form
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How to fill out the Wisconsin Admin Code 10710 Form online
Filling out the Wisconsin Admin Code 10710 Form online is an essential step in the process of requesting prior authorization for proton pump inhibitor suspensions and orally disintegrating tablets. This guide provides detailed instructions to ensure you complete the form accurately and efficiently.
Follow the steps to complete the form with ease.
- Click ‘Get Form’ button to obtain the form and load it in your chosen editor.
- Complete Section I — Member Information. Enter the member’s last name, first name, and middle initial. Use the Wisconsin Enrollment Verification System to ensure the spelling is correct. Provide the member identification number and date of birth in the specified format.
- Proceed to Section II — Prescription Information. Fill in the drug name, strength, date the prescription was written, number of refills, and directions for use. Ensure you accurately capture all required details.
- In Section III — Clinical Information, provide the appropriate diagnosis code and description. This must correspond and be relevant to the drug requested.
- If applicable, complete Section IIIA or IIIB, detailing any clinical information for non-preferred suspensions or orally disintegrating tablets. This includes checking boxes and providing further explanations if necessary.
- Complete Section IV — Authorized Signature by having the prescriber sign and date the form.
- If you are a pharmacy provider using the STAT-PA system, fill in Section V, making sure to enter the National Drug Code, days’ supply requested, NPI, first date of service, place of service code, and applicable PA number details.
- Use Section VI to provide any additional information that may support the request. Ensure all details are included for the review.
- After filling out the form, save your changes, download it for your records, or print it as needed. If applicable, share the form as required.
Begin your process of filling out the Wisconsin Admin Code 10710 Form online today for a smooth and efficient submission.
The Wisconsin Department of Health Services is responsible for overseeing Developmental Service Providers (DSPs) in the state. This department ensures that DSPs comply with regulations designed to provide quality support and services to individuals with developmental disabilities. By monitoring adherence to standards, the department aims to enhance the welfare of those relying on these services. To navigate related legal requirements efficiently, many find the Wisconsin Admin Code 10710 Form beneficial.
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