Get Prior Authorization Fax Completed Form To: 866-254 ...

Filling out the Prior Authorization Fax Completed Form To: 866-254-0761 is a crucial step for patients seeking approval for . This guide will provide you with detailed instructions on how to complete the form accurately and efficiently.

Follow the steps to complete the form online.

1. Press the ‘Get Form’ button to access the Prior Authorization Fax Completed Form.
2. Begin by completing Part I, which needs to be filled out by the physician. Provide the recipient's name, date of birth, and Medicaid ID number, ensuring accuracy in all entries.
3. Next, input the physician's name, Medicaid provider number, telephone number, fax number, and address including city, state, and zip code.
4. Indicate the requested drug and dosage, specifying , and ensure to check off if the tuberculosis test was taken within the last six months.
5. Complete the section regarding the patient's lab monitoring by confirming that lab tests have occurred and results are within acceptable limits for lymphocytes, neutrophils, hemoglobin, lipids, and liver enzymes.
6. Address the patient's history by indicating whether they have had active hepatitis B or C and if they failed therapy, providing start and end dates as applicable.
7. Ensure the physician signatures and date fields are completed to validate the submission.
8. Move to Part II, which must be filled out by the pharmacy, and provide the pharmacy name, North Dakota Medicaid provider number, phone number, fax number, drug, and NDC number.
9. Part III is for official use only, and typically does not require input; however, be aware of its components including approval dates and reasons for denial, if applicable.
10. Once all sections are accurately filled, review your form for any errors. Then, you can save the changes, download, print, or share the completed form as required.

Complete your Prior Authorization Fax Completed Form online today for a smooth application process.