Get 877 486 2621

Filling out the 877 486 2621 form online can seem daunting, but with the right guidance, you can complete it smoothly. This guide will walk you through each section of the form, providing clear instructions tailored to meet your needs.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's name in the designated field. Ensure the name matches the individual's identification documents to prevent any issues with verification.
3. Fill in the prescriber's name, making sure to include their full name as it appears in their records.
4. Provide the member or subscriber number. This number is often found on the patient’s insurance card.
5. Enter the patient's date of birth accurately to confirm their identity and eligibility.
6. Fill in the office contact information to facilitate communication; include the person's name and contact number.
7. Input the group number associated with the patient’s insurance plan.
8. Provide the prescriber’s National Provider Identifier (NPI) number.
9. Enter the prescriber’s office address, including street, city, state, and ZIP code.
10. Include the office phone number for any follow-up communication.
11. If applicable, provide the tax identification number (Tax ID#) for the prescriber.
12. Indicate if the request is expedited or urgent by checking the appropriate box, ensuring to provide a reason if necessary.
13. Enter the drug name that is being requested for authorization.
14. Specify the directions or dosing (SIG) for the drug, including any specific instructions.
15. Fill in the quantity of the medication being requested.
16. Attach any pertinent medical history or additional information that may support the prior authorization request.
17. Answer the subsequent questions regarding J-code, ICD-9 code, and whether the medication is part of an ongoing investigational trial. Provide diagnosis details as needed.
18. Indicate if this request is a reauthorization by selecting yes or no.
19. List any therapeutic alternatives previously used, including start and end dates along with their outcomes.
20. Ensure the prescriber signs and dates the form to validate the request.

Complete your forms online today for a seamless experience.