Follow the steps to complete the authorization form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by entering the patient’s name in the designated field. Ensure that the information is correct and clear to avoid delays.
3. Input the prescriber’s name, ensuring accurate spelling. This step is important for verification purposes.
4. Fill in the member number and fax number as requested. The member number is critical for identifying patient records.
5. Provide the date of birth and contact information for the office, including group number and NPI (National Provider Identifier) if applicable.
6. Complete the address fields, including city, state, and zip code. This ensures that any correspondence is sent to the correct location.
7. Select the drug name from the list provided, along with selecting if the request is for expedited/urgent processing.
8. Indicate whether this is the initial or continuing therapy by selecting the appropriate option. If it is continuing therapy, provide the date therapy started.
9. Record the patient's diagnosis and answer subsequent questions about the patient's smoking status and previous therapies clearly.
10. Ensure that all required details, such as age confirmation and previous smoking cessation therapy failures, are filled out accurately.
11. Add any supporting clinical statements or documentation that may strengthen the authorization request, as required by the form.
12. Finally, the prescriber must sign and date the form to verify that all information is accurate and complete.
13. Once all fields are completed, save the changes to the form. You can then choose to download, print, or share the completed document as necessary.

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