Get Maximum Unit Override Request Form - Mississippi Division Of ... - Medicaid Ms

Filling out the Maximum Unit Override Request Form is an essential process for obtaining prior authorization for medication discrepancies. This guide provides clear, step-by-step instructions to help users navigate the form efficiently.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Maximum Unit Override Request Form and open it in the designated editing area.
2. Begin by providing the beneficiary's information in the designated fields. Enter the beneficiary’s name, Medicaid number, city, and date of birth, ensuring accuracy in each entry.
3. Move to the prescriber information section. Enter the National Provider Identifier (NPI) number, the prescribing physician's name, Medicaid ID number, city, state, phone number, and fax number.
4. In the certification area, confirm your role as the ordering physician, nurse practitioner, or physician assistant. Provide your signature and the date to validate the request.
5. Next, fill out the pharmacy information by entering the dispensing pharmacy's name, provider ID number, city, state, phone number, and fax number.
6. Proceed to the drug/clinical information section to enter the drug name and strength requested. Specify the maximum quantity needed and the diagnosis.
7. Complete the medical justification by providing a detailed explanation for the request. This should clarify the necessity of the medication for the beneficiary.
8. Once all fields are filled out, review the information for accuracy. Users can then save changes, download, print, or share the completed form as needed.

Complete your Maximum Unit Override Request Form online to ensure timely processing of your medication needs.