Get Prior Authorization Request - Sfn 1115 - State Of North Dakota

Filling out the Prior Authorization Request - SFN 1115 is essential for obtaining necessary medical equipment or supplies for patients. This guide provides users with clear, step-by-step instructions to successfully complete the form online, ensuring a smooth submission process.

Follow the steps to complete and submit the Prior Authorization Request online.

1. Press the ‘Get Form’ button to access the Prior Authorization Request - SFN 1115 and open it in your online editor.
2. Begin by entering the patient's name, including their last name, first name, and middle name, if available.
3. Provide the patient's date of birth and Client I.D. Number accurately in the designated fields.
4. Fill in the patient's address and indicate their primary and secondary insurance information.
5. In Section I, the prescribing physician must list the item prescribed, include the relevant diagnosis and prognosis code, and provide a detailed explanation of medical necessity, duration of need, and date of visit.
6. The physician must then print their name, provider number, sign the form, and date it.
7. Move to Section II, where the provider (supplier) should input their name, contact numbers, address, and provider number.
8. List the proposed medical equipment or supplies within this section. Ensure the description is comprehensive and indicates both the rental or acquisition costs.
9. Confirm whether this request is an adjustment to an existing authorization and provide details if applicable.
10. Review all sections for accuracy and completeness before saving or submitting the form online.
11. Finally, once completed, either save your changes, download a copy, print the form, or share it as required.

Complete the Prior Authorization Request - SFN 1115 online today to ensure timely access to necessary medical services.