Get Qual Med Prior Authorization / Medication Exception Fax Form

Completing the Qual Med Prior Authorization / Medication Exception Fax Form is essential for requesting approval for medication exceptions. This guide will provide a clear, step-by-step approach to effectively fill out the form online, ensuring all necessary information is included to avoid processing delays.

Follow the steps to accurately complete the form:

1. Press the ‘Get Form’ button to obtain the form and open it in the designated editor.
2. Enter the patient’s name in the format of last name, first name, and middle initial.
3. Fill in the Member ID number associated with the patient.
4. Provide the medication name and its strength in the corresponding field.
5. Indicate the quantity of medication requested.
6. Answer whether this is a new medication for the patient by selecting either ‘Yes’ or ‘No’.
7. Input the date of birth of the patient.
8. Detail the directions for use and the duration for which the medication is prescribed.
9. Record the date the medication was first started.
10. Enter the diagnosis related to the medication request.
11. Fill in the ICD-9 code pertaining to the diagnosis.
12. List any formulary drugs that have been tried or previous therapies along with their respective dates of use.
13. Provide medical justification for the requested drug, including any relevant chart notes and lab results.
14. Input the physician’s name (last name, first name, middle initial) who is making the request.
15. Include the name of the contact person for this request.
16. Record the date of filling out the form.
17. Specify the specialty of the physician.
18. Fill in the contact email address for follow-up.
19. Provide the pharmacy name associated with the request.
20. Enter the physician's address.
21. Fill in the contact phone number and fax number for the physician.
22. Provide the pharmacy phone and fax numbers.
23. Complete any additional fields if specified, including any comments or decisions for PacificSource use only.
24. Once all fields are completed, save your changes, and choose to download, print, or share the form as needed.

Complete your Qual Med Prior Authorization / Medication Exception Fax Form online today to ensure timely processing.