Get Gateway Prior Authorization Form

The Gateway Prior Authorization Form is an essential document needed to request approval for non-formulary drugs. This guide will provide clear and concise instructions on how to fill out the form online, ensuring a smooth and efficient process for users.

Follow the steps to complete the form online effectively.

1. Click ‘Get Form’ button to acquire the form and open it in your preferred online platform.
2. Complete Section A - Member Information. Enter the member's last name, first name, date of birth, member ID, and allergies. Document the type of reaction if any.
3. Move to Section B - Pharmacy Information. Fill in the pharmacy name and pharmacy phone number.
4. Proceed to Section C - Clinical Information. Indicate the drug name requested, dosage and frequency, quantity, and length of therapy. Also, specify the diagnosis for which the drug is requested.
5. Document any formulary alternatives that have been used by the patient. List the drug name/strength, dates tried, and reasons for therapy failure or discontinuation.
6. Indicate if the member is currently or recently hospitalized by checking 'Yes' or 'No.' If 'Yes,' provide the date of discharge and reason for hospitalization.
7. Include any additional clinical or supporting information such as current office notes, lab data, and relevant medical literature.
8. Complete Section D - Prescriber Information. Enter the prescriber's name (printed), specialty, NPI number, office phone, and office fax.
9. Have the prescriber sign and date the form.
10. Once all sections are completed, review the information for accuracy. You can then save changes, download, print, or share the completed form.

Start filling out your Gateway Prior Authorization Form online today.