Get Prior Authorization Form - Maxcare

Completing the Prior Authorization Form for MaxCare is an essential step in obtaining the necessary approval for medication. This guide will provide you with a clear, step-by-step approach to successfully filling out the form online.

Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to obtain the Prior Authorization Form and open it for editing.
2. Fill in the patient details at the top of the form including the patient's name, date of birth (DOB), age, height, weight, and member ID number.
3. List any drug allergies that the patient may have to ensure safety during medication approval.
4. Fill in the physician's details, including the physician's name, specialty, provider's address, NPI number, phone number, and fax number.
5. In the 'Medication needed for approval' section, provide the name of the drug, dosage, quantity requested, signature (sig), duration, and indication for the prescription.
6. State the diagnosis related to the medication request in the designated area.
7. Document any previous treatments the patient has received that relate to this request, along with the length of treatment.
8. Indicate whether this request exceeds the plan quantity limit by selecting 'Yes' or 'No'.
9. Specify if this is a new start to the requested therapy by answering 'Yes' or 'No.' If the answer is 'No', provide the date of the last dose.
10. Include any additional pertinent information that may support the authorization request.
11. Ensure that the prescriber signs the form, as this is required for processing.
12. Attach any lab results and relevant documentation before submitting the form.
13. Once all fields are completed, save changes, download, print, or share the form as necessary.

Start filling out your form online today for timely medication approval.