Get Allegian Insurance Authorization Form

Filling out the Allegian Insurance Authorization Form is an essential step in requesting prior authorization for necessary medications. This guide provides comprehensive, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the Allegian Insurance Authorization Form online

1. Click ‘Get Form’ button to obtain the Allegian Insurance Authorization Form and open it for editing.
2. Enter the date of request in the designated field. This date helps track the request timeline.
3. Fill in the sender's name. This should be the name of the individual completing the form.
4. Provide the requesting provider's name, including both first and last names, in the appropriate section.
5. Complete the address section for the requesting provider. Include street address, city, state, and zip code.
6. Input the provider’s phone number and fax number to ensure communication regarding the request.
7. Fill in the patient’s name, along with their insurance ID number and date of birth.
8. Specify the drug name, strength, dosage or frequency, and duration of treatment in the respective fields.
9. Include the relevant ICD-9 code and the begin date for the requested treatment.
10. Provide a description of the diagnosis to support the request. Ensure that the explanation is detailed and necessary.
11. Document the clinical history that supports the diagnosis, ensuring to include any relevant medical history.
12. Fill out the drug history and indicate if there have been any failed treatments.
13. If applicable, provide a laboratory history and the Hepatitis C genotype if relevant to the request.
14. Once all fields are completed, review the document for accuracy. Save changes, and then you can choose to download, print, or share the form.

Complete your Allegian Insurance Authorization Form online today for a seamless prior authorization process.