Get Form - Department Of Public Welfare - Dpw State Pa

Filling out the Form - Department Of Public Welfare - Dpw State Pa online is a straightforward process that helps facilitate prior authorization for . This guide aims to provide clear instructions for accurately completing the form.

Follow the steps to complete the form effectively.

1. Click 'Get Form' button to obtain the form and open it in your chosen document management tool.
2. Begin with the 'Prior Authorization Request Information' section. Select the appropriate box for 'New,' 'Renewal,' or 'Additional Information.' Fill in the coordinator's name and the number of pages for this request.
3. In the 'Recipient Information' section, enter the recipient’s name, recipient ID number, chronological age, date of birth, and gestational age.
4. Proceed to the 'Prescriber Information' section. Input the prescriber’s name, NPI number, specialty, or medical assistance provider ID, state license number, and the prescriber’s address, including suite number, city, state, and zip code. Include the fax and phone numbers.
5. In the 'Medical Information' section, record the current weight in pounds and ounces, and convert this to kilograms as required. Calculate the dose based on the formula provided and record the total mg dosages.
6. Indicate the number of doses requested in months. Review and check which criteria apply to the recipient based on gestational age and associated risk factors. Provide supporting documentation where required.
7. Select the specialty pharmacy the recipient wishes to use, either Accredo Health Group or Walgreen’s Specialty Pharmacy.
8. Complete the form by adding the prescriber’s signature and date. Ensure that all sections have been filled accurately.
9. Finally, save your changes, and print or share the completed form along with any required clinical information supporting the request.

Complete your documents online today to ensure timely processing.