Get Express Scripts Prior Authorization Form 2019

The Express Scripts Prior Authorization Form 2019 is an essential document for requesting approval for medication. This guide will provide you with clear, step-by-step instructions to help you complete the form online efficiently.

Follow the steps to fill out the Express Scripts Prior Authorization Form 2019 online

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Begin by filling in the patient information. Enter the first name, last name, date of birth, patient ID, and phone number accurately.
3. Next, complete the prescriber information section. Input the prescriber’s name, DEA/NPI number, phone number, fax number, and address, including the state and zip code.
4. Specify the primary diagnosis and include the corresponding ICD code.
5. Indicate the requested drug and strength by checking the appropriate box for options.
6. Fill out the directions for use by providing details such as frequency and quantity.
7. Complete the clinical assessment questions by checking ‘Yes’, ‘No’, or ‘N/A’ for each query regarding the patient’s history with and other treatments.
8. If applicable, provide information about prior therapies attempted by the patient and any pertinent comments or additional diagnoses.
9. Ensure all information is accurate and complete. The prescriber should sign and date the form and provide an office contact name and number.
10. Once you have reviewed the completed form, save your changes, then you can download, print, or share the document as needed.

Start completing your forms online today for a smoother prior authorization process.