Get 2014 Prior Authorization Form- - Coventry Health Care

This guide provides comprehensive instructions on filling out the 2014 Prior Authorization Form for Coventry Health Care. By following these steps, you will ensure accurate completion of the form to facilitate the authorization process.

Follow the steps to successfully complete the form online.

1. To begin, click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Enter the patient’s details, including their name, member ID, phone number, and date of birth. Ensure that all information is accurate to prevent delays.
3. Complete the section for the requesting physician. Add their name, DEA number, office phone, fax number, address, and tax ID number.
4. In the medication information section, select the drug requested by marking the box next to '' and specify the strength and frequency of use.
5. Indicate the diagnosis by selecting the appropriate option(s) from major depressive disorder, schizophrenia, bipolar disorder, or autistic disorder (age 6-17 years). If applicable, specify any other diagnosis.
6. Answer whether the patient is currently taking the medication and provide details of any past medications used along with their treatment dates.
7. Document the therapeutic outcomes and include any additional comments that might support the request.
8. Ensure the physician’s signature is included, along with their specialty if applicable.
9. Finally, review the document for completeness. After ensuring all fields are filled correctly, save changes, and follow the guidelines to fax the completed form to 1 (800) 639-9158 for processing.

Start completing the 2014 Prior Authorization Form online today to expedite your authorization requests.