Get Calviva Pa Form 12-12.doc

Filling out the CalViva PA Form 12-12.doc online is a straightforward process that requires careful attention to detail. This guide will assist you in understanding each section of the form to ensure accurate submissions.

Follow the steps to complete the form accurately and efficiently.

1. Click the ‘Get Form’ button to access the CalViva PA Form 12-12.doc and open it in your preferred editing tool.
2. Enter the patient’s last name, first name, and middle initial in the designated fields. Ensure all names are spelled correctly.
3. Fill in the member ID number and the patient's date of birth. Accurate information is crucial for processing.
4. Complete the patient's street address, city, state, and zip code with clear and precise details.
5. Indicate the prescriber’s last and first name, their specialty, and phone number, ensuring you provide a clear contact point.
6. List the medication name and strength, making sure to detail the quantity prescribed and directions for use.
7. Specify the date of the first dose to be administered.
8. Provide the diagnosis and corresponding ICD-9 code to support the request.
9. Document any allergies the patient may have, as well as medications tried or previous therapies, including dates of use.
10. Articulate the medical justification for the requested drug clearly and thoroughly in the provided space.
11. If applicable, enter the specialty pharmacy fax number for where relevant information can be sent.
12. Indicate if the medication will be administered at a provider’s office or at home. Include the medication vendor’s name if necessary.
13. Finalize the form with the prescriber’s signature and date to confirm authenticity.
14. After completing all the sections, review the form for accuracy, save your changes, and download or print it if needed or share it with relevant parties.

Complete your CalViva PA Form 12-12.doc online today for a seamless authorization process.