Get 800 548 5524

This guide provides detailed instructions on how to accurately fill out the 800 548 5524 form online. By following these steps, users can ensure a smooth submission process for their requests.

Follow the steps to properly complete the 800 548 5524 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's name in the format of last, first, and middle initial. This is crucial for identification purposes.
3. Input the patient's date of birth using the specified format: MM / DD / YYYY.
4. Provide the member ID number. Ensure that you print clearly and enter one digit per box to avoid confusion.
5. Next, enter the patient's phone number, again ensuring clarity and one digit per box.
6. Fill in the patient's address, including the city, state, and zip code to ensure correct routing of information.
7. Select the patient's gender by marking the appropriate box.
8. Enter the provider's name in the last, first, and middle initial format.
9. Specify the provider's specialty and provide the provider's address, including city, state, and zip.
10. List any allergies the patient has to ensure safety in medication administration.
11. Provide the name of the contact person, along with their NPI number to facilitate communication.
12. Enter the provider's phone number and fax number, taking care to print clearly.
13. Fill out the quantity and direction for use and duration of the medication prescribed.
14. Record the medication name and strength administered, along with the diagnosis.
15. Complete the section regarding previous medications tried and the medical justification for the current request.
16. If applicable, complete the sections for commercial and Medicare members as directed, ensuring all questions are answered accurately.
17. Certify that the information is correct by signing the form as the physician, along with the date.
18. Finally, review the entire document for accuracy, then save changes, download, print, or share the form as necessary.

Complete your prior authorization request online today for efficient processing.