Get Affinity Prior Auth Form

The Affinity Prior Auth Form is essential for submitting requests related to medication coverage under Medicare Part D. This guide will provide a clear and supportive approach to assist you in accurately completing the form online.

Follow the steps to successfully complete the Affinity Prior Auth Form.

1. Click ‘Get Form’ button to access the Affinity Prior Auth Form and open it in your document editor.
2. Begin by entering the patient’s information. Fill in the patient’s name, member ID number, address, city, state, zip code, and date of birth accurately in the designated fields.
3. Provide the prescriber information. Enter the prescriber’s name, NPI number (if available), address, city, state, and zip code, along with their home phone and office phone numbers.
4. In the 'Diagnosis and Medical Information' section, note the medication details. Fill in the strength and route of administration, frequency, expected length of therapy, date therapy was initiated, patient’s height and weight, drug allergies, and diagnosis.
5. Select 'New Prescription' if applicable and input the quantity of medication required.
6. In the 'Rationale for Exception Request or Prior Authorization' section, provide a detailed explanation as this form cannot be processed without it. Choose the relevant criteria for the request and specify the required information for each situation.
7. If an expedited review is necessary, check the corresponding box and ensure the prescriber’s signature is included, along with the date.
8. Review all information entered for accuracy. Once verified, you may choose to save changes, download, print, or share the completed form as needed.

Start completing the Affinity Prior Auth Form online today to ensure timely processing of your request.