Get Coventry Prior Authorization Form

Filling out the Coventry Prior Authorization Form online is a straightforward process that ensures proper authorization for medication requests. This guide provides step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete the form correctly

1. Use the ‘Get Form’ button to access the Coventry Prior Authorization Form and open it in your preferred online editor.
2. Begin by entering the patient's name, member ID number, phone number, and date of request in the designated fields.
3. Input the patient's date of birth, plan ID, benefit, requesting physician's name, DEA number, office phone number, office fax number, and office address.
4. Add the tax ID number of the requesting physician to the appropriate section of the form.
5. For medication information, indicate the requested drug, dosage, and frequency, specifying and its dosing in the provided fields.
6. Identify the patient’s diagnosis by checking the appropriate box. Include office notes and any necessary diagnostic information.
7. In the section for current or past medications, specify the medications used, dates of treatment, and therapeutic outcomes.
8. Provide any additional comments regarding the patient's condition or request if necessary.
9. If making an exception request, complete that section by clearly stating the specific requirement not met and the reason for the exemption.
10. Finally, ensure all information is complete and legible, then sign the form as the requesting physician.
11. Once finished, save your changes, and you can choose to download, print, or share the completed form.

Start filling out your Coventry Prior Authorization Form online today for a smooth submission process.