Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to acquire the authorization form, allowing you to open it in your online editor.
2. Begin by entering the date at the top of the form to indicate when you are submitting the request.
3. Complete the Patient Name field with the full name of the individual for whom you are requesting coverage.
4. Fill out the Physician Name field with your name, ensuring that all details are accurate.
5. Enter the Patient ID number to identify the individual within the system.
6. Provide your Physician NPI number to certify your professional identification.
7. Include the Patient Date of Birth to confirm the age of the individual related to the request.
8. Input your Telephone Number and Fax Number to ensure they can contact you if needed.
9. In the Diagnosis/Reason for Medication Request field, specify the medical reason for the requested medication in detail.
10. Fill in the Pharmacy used by the Patient, along with the Pharmacy Telephone Number and Fax Number.
11. Identify the Drug Requested in the designated field to specify what medication you are requesting authorization for.
12. Indicate if this request is Urgent by selecting the appropriate option, noting the specifics necessary for urgency.
13. Provide the Dose/Strength and Length of Treatment in the specified fields for clear understanding of the request.
14. Complete the Quantity (per month) and Route of administration to give clarity on dosage and administration methods.
15. List Other Medications Tried and/or Failed, detailing specific treatments attempted and attaching necessary documentation.
16. Finally, secure the form with your Prescriber signature, and complete the Submitted by and Title fields to finalize the request.
17. Enter the required Date, Direct Phone Number and save, download, or print a copy of the completed form for your records.

Take action now and complete your La Care Prior Authorization Form online to ensure timely coverage for your patients.