Get Prior Authorization Request Form - Anthem

Completing the Prior Authorization Request Form for Anthem is an important step in ensuring that necessary medications are approved efficiently. This guide will walk you through the process of filling out the form online, ensuring you provide all required information accurately.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter the physician information in the designated fields. Include the physician's name, DEA number, phone number, specialty, fax number, and address. Be sure to have the physician sign and date the form.
3. Fill out the patient information section, providing the policyholder or insured's name, ID number, the patient's name, birthdate, and sex.
4. Complete the medication information section. Specify the requested medication, its strength, dosage, quantity for a 30-day supply, duration of therapy, and the form (tablet, injection, nasal spray, or other).
5. If applicable, provide an explanation for any dosage exceeding the maximum allowable. List previous medications the patient has tried for the condition along with their most recent prescription dates.
6. In the diagnosis and all other medical conditions section, describe the diagnosis for the requested medication. Reference any recent test results relevant to the treatment choice, including test names, results, reference lab ranges, and dates.
7. List any medications the patient is currently taking and the dates they were originally prescribed.
8. If you have additional information regarding the request, provide it in the designated section.
9. Lastly, designate a contact person from the office for follow-up, along with a contact phone number for any inquiries.
10. After completing all sections, review the form for accuracy. Save any changes made, and proceed to download, print, or share the completed form as necessary.

Complete your forms online today for a streamlined authorization process.