Get Express Scripts Pa Form Printable

Filling out the Express Scripts Pa Form Printable online can streamline the process of obtaining prior authorization for medications. This guide will help you navigate each section of the form and ensure you provide the necessary information for a successful submission.

Follow the steps to complete the Express Scripts Pa Form Printable

1. Press the ‘Get Form’ button to access the form and open it in your editor.
2. Fill in the patient information section by providing the first and last name, date of birth, patient ID number, and phone number.
3. Complete the prescriber information with the prescriber's name, DEA/NPI number, contact information, and address.
4. Indicate the primary diagnosis and the corresponding ICD code.
5. Select the requested drug and strength from the list of Cialis options available.
6. Provide directions for use, specifying dosage frequency and quantity.
7. Complete the clinical assessment questions regarding the patient's diagnosis and previous therapies. Answer each question with a checkmark for 'Yes', 'No', or 'N/A'.
8. In the comments section, add any other important information the prescriber believes is relevant for the review.
9. Obtain the prescriber’s signature and date the form. Ensure the office contact name and phone number are also provided.
10. Once all sections are completed, save your changes to the form. You may then download, print, or share the filled form as needed.

Complete your documents online today for efficient submission!