Get Cl-472 (rev. 8-2010).indd. Part D Drug Authorization Request Form - Alseib

Filling out the CL-472 (Rev. 8-2010).indd. Part D Drug Authorization Request Form - Alseib is essential for requesting medication authorizations. This guide provides step-by-step instructions to help you complete the form correctly and efficiently.

Follow the steps to fill out the Part D Drug Authorization Request Form online

1. Press the ‘Get Form’ button to acquire the form, and open it in your preferred editor.
2. In Section 1, provide your employee information. Fill in your first name, middle initial, last name, date of birth, and Preferred Blue account number. Ensure you include your company name and contact numbers as required.
3. In Section 2, enter your health FSA/HRA reimbursement information. Clearly specify types of services received, including medical, vision, dental, orthodontics, or other services. Use separate entries for each eligible expense.
4. For each expense, provide detailed information: the patient’s name, relationship to you (self, spouse, dependent), date of service, type of charge, and if covered by insurance. Include the amount you are requesting reimbursed.
5. Attach all pertinent documents such as itemized bills and proof of payment that include a description of service, date provided, and charge amount. Ensure no items are highlighted on receipts.
6. After filling out all sections, verify that you have signed and dated the form. An unsigned form will not be processed.
7. Finally, choose to save your changes, download the completed form, print it out, or share it as necessary. You may also fax or mail your completed form to the appropriate address.

Begin filling out your Part D Drug Authorization Request Form online today!