Get Blue Cross Prior Auth Form

Filling out the Blue Cross Prior Auth Form is an essential step for securing prior authorization for therapy. This guide will help you navigate the process with ease, ensuring that all necessary information is accurately provided.

Follow the steps to complete the form seamlessly.

1. Click the ‘Get Form’ button to obtain the form and open it for editing.
2. Enter today's date in the designated field.
3. Provide the patient's information, including their first and last name, middle initial, date of birth (mm/dd/yyyy), address, city, state, zip code, and telephone number.
4. Input the required insurance information, which includes the BCBS ID number and group number.
5. Fill out the physician or clinic information by entering the prescriber's name, NPI number, specialty, clinic name, address, city, state, zip code, phone number, contact name, and secure fax number.
6. Attach any additional documents that may support the request.
7. Specify the medication requested, which in this case is 10mg, and indicate the dosing schedule.
8. Answer the clinical questions regarding the prescriber’s specialty, patient's diagnosis, concurrent therapy, history of seizures, and creatinine clearance. Provide clear and accurate responses.
9. For renewal therapy, provide the baseline and current timed 25-foot walk results for the patient.
10. List all reasons for selecting the requested strength, dosing schedule, and quantity. Make sure to justify your choices adequately.
11. Once all fields are completed, make sure to save your changes. You can then download, print, or share the completed form as required.

Complete the Blue Cross Prior Auth Form online to ensure your request is processed efficiently.