Get Personal Choice Prior Authorization Form

Completing the Personal Choice Prior Authorization Form online can streamline the process of requesting medication approvals. This guide provides clear instructions to help users efficiently fill out the form with confidence.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the Personal Choice Prior Authorization Form and open it in your preferred online editor.
2. Begin by entering the current date in the designated space at the top of the form. This helps to establish the timeline for the authorization request.
3. In the patient information section, clearly print the patient's full name, patient ID number, address, city, state, ZIP code, telephone number, date of birth, height, and weight. Accurate information is essential for identifying the patient and processing the request.
4. Specify the delivery preference for the medication by selecting either 'N/A – No delivery requested, authorization only' or 'Delivery requested.' If delivery is needed, indicate where the medication should be sent: either the physician's office or the patient’s home.
5. Complete the prescribed drug/statement of medical necessity section. Enter the prescribed drug name, its strength, dosage instructions (Sig), dispense quantity, and number of refills if applicable.
6. Select the prescription options: either 'Substitution permissible' or 'Dispense as written' based on the physician's instruction.
7. Once all sections are completed and verified for accuracy, you can save the changes, download the completed form, and decide whether to print or share it as necessary.
8. Finally, fax the completed form to 215-761-9165. Expect a response by fax within two business days from your submission.

Start filling out your Personal Choice Prior Authorization Form online today for a smoother medication request process.