Get Anticoagulant Prior Authorization Form.doc. Evidence Of Coverage Medicare Prescription Drug

The Anticoagulant Prior Authorization Form is an essential document for obtaining prior approval for specific anticoagulant medications. This guide provides you with detailed, step-by-step instructions to complete the form accurately and efficiently.

Follow the steps to complete your anticoagulant prior authorization form.

1. Press the ‘Get Form’ button to acquire the form and open it in your chosen application.
2. Fill in the requesting physician section: Enter the requesting physician's name, call center ID, tax ID number, office fax number, and office address.
3. Complete the member information section: Enter the patient’s name, member ID, date of birth, and the date of request.
4. Provide contact information: Include the office contact name, plan ID, benefit details, and phone number.
5. In the medication information section, select the requested medication by checking the appropriate box next to , , , , or .
6. Specify the dosage: Clearly state the requested dose, frequency, and duration of therapy.
7. Indicate the reason for requesting the medication: Check the box that describes the request's indication, such as DVT prophylaxis or treatment, and provide any necessary details.
8. Document the patient's weight to support the medication's appropriateness.
9. Submit any required progress notes, as medical necessity is needed for all long-term therapy requests.
10. Lastly, ensure the requesting physician signs the form and indicates their specialty before submission.
11. Once completed, save your changes, download a copy, print it, or share the form as needed.

Take action now and complete your documents online for a streamlined process.