Get Specialty Medication Prior Authorization Form - Absolute Total Care

Filling out the Specialty Medication Prior Authorization Form is a crucial step to ensure that necessary medications are provided in a timely manner. This guide will walk you through the process of completing the form online, making it easier for you to submit your request efficiently.

Follow the steps to effectively complete your authorization request.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the patient information section. Include the patient’s name, address, city, state, zip code, home and alternate phone numbers, date of birth, and gender.
3. Next, provide the prescriber information. Enter the prescriber’s name, office contact information, NPI number, associated group or hospital name, and the complete address including city, state, and zip.
4. In the insurance information section, input details for primary and secondary insurance. Record the insurance names, respective ID numbers, and phone numbers.
5. For the statement of medical necessity, provide the patient's diagnosis along with ICD9 codes and a description. Include the date of diagnosis, any relevant clinical information, and lab data if available.
6. In the additional clinical information section, include the patient's weight and height, any other medications being taken, and additional comments or clinical findings if necessary.
7. Indicate whether the member is currently treated with the requested medication(s) and if this request is a continuation of a previous approval. Record if there have been changes in strength, dosage, or quantity.
8. List the medication(s) being requested, including the medication name, strength/dose, quantity, number of refills, and therapy start date.
9. Finally, ensure the prescriber signs the form, dates it, and completes any directions associated with the prescribed therapy.
10. Once all information is completed, review for accuracy, then save changes, download, print, or share the form as required.

Complete your Specialty Medication Prior Authorization Form online today to facilitate swift processing of your request.