Loading
Get Staywell Prior Auth Form
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Staywell Prior Auth Form online
Completing the Staywell Prior Auth Form online can streamline the authorization process for necessary care. This guide provides a clear and user-friendly approach to ensuring all required information is accurately submitted.
Follow the steps to complete the Staywell Prior Auth Form online.
- Click ‘Get Form’ button to obtain the form and open it in the online editor.
- Fill in the member ID# and provider ID# at the top of the form. Ensure that all information is accurate and clearly printed.
- Enter the patient's name, address, city, state, phone number, date of birth, and date recorded. Double-check for spelling errors.
- Provide the patient's weight (Wt) and height (Ht) in the designated fields. These measurements are critical for the authorization process.
- Select the appropriate therapy option, including 'Initial', 'Continuation of Existing', or 'Restart After 90 Days', based on the patient's treatment history.
- Answer the questions regarding the patient’s BMI and cardiovascular risk factors. Provide clear indications of whether the conditions apply by marking 'Yes' or 'No'.
- If applicable, list any co-morbid conditions that may contraindicate the use of Orlistat. Check all relevant boxes as required.
- Indicate if the patient is on any prescribed medications for weight reduction. Note that only the approved dosage is 120mg po TID.
- Attach any pertinent laboratory reports that must have been obtained within the previous 30 days. This documentation is crucial for approval.
- Finally, ensure the physician’s signature is complete. Save all changes to the form, and you can choose to download, print, or share it as needed.
Complete the Staywell Prior Auth Form online today to expedite your authorization process.
To obtain prior authorization, begin by checking if your service or medication requires it. Next, complete the Staywell Prior Auth Form, ensuring you include all required details. You can then submit the form to your healthcare provider or insurance company, who will review your request and provide a decision.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.