Get Cash Waiver Form.doc - Mainecarepdl

Filling out the Cash Waiver Form is an essential step for users seeking Prior Authorization for specific medications through MaineCare. This guide provides comprehensive instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to effectively complete the Cash Waiver Form.

1. Click the ‘Get Form’ button to access the Cash Waiver Form and open it for editing.
2. Enter the date in the designated field. This helps to establish the timeline for the request.
3. In the 'Member Name' section, clearly print the full name of the individual requesting the waiver.
4. Provide the 'Member ID#' in the appropriate field to link the request to the member's account.
5. Fill in the 'Pharmacy NAPB' and 'Pharmacy NPI' to identify the pharmacy dispensing the medication.
6. In the 'Prescriber Name' field, enter the name of the licensed healthcare provider who prescribed the medication.
7. Provide the 'Prescriber DEA#' to verify that the prescriber is authorized to prescribe controlled substances.
8. Clearly indicate the 'Medication Needing PA' by writing the specific name of the medication that requires Prior Authorization.
9. In the 'Quantity Requested' field, specify the amount of medication being requested, followed by the 'Days Supply' section to indicate the duration for which the medication is needed.
10. Insert the 'Amount Paid' to show any payment made or expected for the medication.
11. Read the terms provided about the Prior Authorization requirement and sign in the 'Member Signature' field to acknowledge understanding.
12. If applicable, have the pharmacy representative sign in the designated spot to confirm their involvement.
13. After reviewing all entries for accuracy, save your changes. You have options to download, print, or share the completed form accordingly.

Start completing your documents online to ensure you meet all necessary requirements.