Get Physician Fax Form - Bcbstx.com

This guide provides clear and detailed instructions for users on how to complete the Physician Fax Form used for requesting preauthorization for anticonvulsants. Properly filling out each section is essential to ensure timely processing of your request.

Follow the steps to successfully complete the Physician Fax Form.

1. Press the ‘Get Form’ button to acquire the form and open it in the designated editor.
2. Fill in the current date in the designated 'Today’s Date' field to ensure the request is processed in a timely manner.
3. Enter the patient information, including their first and last name, address, phone number, and date of birth (mm/dd/yyyy). This is crucial for identifying the patient.
4. Provide the insurance information, including the Blue Cross Blue Shield ID number and group number. This information is essential for verifying coverage.
5. Complete the physician and clinic information section. This includes the prescriber’s name, NPI number, specialty, clinic name, and contact details for efficient communication.
6. In the diagnosis and medication requested section, clearly state the patient's diagnosis and the medication being requested.
7. Indicate whether the patient is currently being treated with the requested medication by selecting 'Yes' or 'No'. If 'Yes', provide the date treatment commenced.
8. List all medications the patient is currently taking for this diagnosis, ensuring a comprehensive record is provided.
9. Document any medications the patient has previously tried and failed for treatment, specifying if brand-name, generic, or over-the-counter products were used.
10. If applicable, answer the questions regarding treatment with specified medications for migraine or neuropathic pain, providing 'Yes' or 'No' responses and any contraindications.
11. Finally, articulate the reasons for selecting the requested medication over potential alternatives, including any allergies or history of adverse reactions.
12. Once all fields are completed, you may save changes, download, print, or share the form as necessary.

Complete your Physician Fax Form online to ensure swift processing of preauthorization requests.