Get Coventry Prior Authorization Form For

Filling out the Coventry Prior Authorization Form is a crucial step in obtaining approval for ® treatment. This guide provides clear instructions for users, ensuring that all necessary information is accurately submitted to facilitate the authorization process.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the patient’s name, member ID number, phone number, and the date of request in the designated fields. Ensure all information is correct to avoid delays.
3. Provide the patient’s date of birth and plan ID. This identification is crucial for processing the authorization effectively.
4. Complete the section for the requesting physician by entering the physician’s name, DEA number, office phone number, fax number, and office address.
5. Indicate whether this is a new medication request or a continuation of therapy. If it is a continuation, include the start date.
6. Select the patient’s diagnosis from the options provided. If 'Other' is selected, specify the diagnosis in the space provided.
7. Fill in the requested dosage for ®. This information is crucial for determining coverage.
8. List past treatment trials relevant to the patient’s diagnosis. Document each medication used, the dates of treatment, and the therapeutic outcomes.
9. Specify any medications that will be used in combination with ® for this diagnosis.
10. Submit any relevant progress notes related to the request and include additional comments if necessary.
11. If the request is urgent, call the appropriate urgent request number provided on the form.
12. For exceptions to utilization management requirements, complete the designated section providing reasons for the exemption.
13. Finalize the form by ensuring all fields are complete and legible. After double-checking, save your changes, download, print, or share the form as needed.

Ensure timely processing of your request by completing the Coventry Prior Authorization Form online today.