Get Passport Prior Authorization Form

This guide provides step-by-step instructions for completing the Passport Prior Authorization Form necessary for obtaining ® or ®. By following these detailed directions, you will ensure that your request is submitted accurately and efficiently.

Follow the steps to effectively complete the form online.

1. Press the ‘Get Form’ button to access the Passport Prior Authorization Form and open it in your preferred document editor.
2. Fill in the patient’s name, member ID number, and contact information including the address, phone number, and date of birth.
3. Complete the physician’s information, ensuring to include their name and DEA number with ‘X’ if applicable, as well as their contact details.
4. Indicate the drug requested, choosing between ® or ®, and fill in the specified dosage, quantity, and instructions for usage.
5. Provide the ICD-9 diagnosis code and any relevant treatment plans, specifying the anticipated length of therapy.
6. For initial requests, verify that all required criteria are checked and provide explanations where necessary on the second page of the form.
7. If submitting a renewal request, ensure consistency of information regarding prior usage of ® and involvement in counseling.
8. Complete the rationale section if criteria are not met, explaining the medical necessity for the requested treatment.
9. Obtain the prescriber’s signature, add the date, and ensure all sections of the form are filled out completely to avoid any delays.
10. Once all information is accurate, save your changes, and prepare to either download, print, or share the completed form as needed.

Complete your Passport Prior Authorization Form online today for a seamless submission process.