Get Atypical Antipsychotics Prior Authorization Request Form - Georgia ... - Dch Georgia

Completing the Atypical Antipsychotics Prior Authorization Request Form is essential to ensure timely access to necessary medications. This guide will walk you through each section of the form to ensure that users can fill it out accurately and efficiently.

Follow the steps to successfully complete your request form.

1. Press the ‘Get Form’ button to acquire the document and open it for completion.
2. Begin with the member's information: Fill in the last name, first name, ID number, and date of birth of the member requiring medication.
3. Next, provide prescriber details: Enter the last name, first name, NPI number, phone number, fax number, and address of the prescribing healthcare provider.
4. List the medication(s) requested: Specify the name, strength, and dosage directions for each medication. Indicate if this request is for tapering off a medication and the dosage form.
5. Identify the member’s diagnosis: Check the appropriate diagnosis from the list provided. If none apply, select 'Other' and specify.
6. Indicate referral information: State if the member is being referred to a psychiatrist, awaiting an appointment, and include the date and name of the psychiatrist if applicable.
7. Provide the member's age: Check the appropriate age category provided.
8. If the member is under the FDA-approved age for any requested medication, make sure to complete Section E on page 3.
9. Fill out the monitoring plan: Indicate whether there is a plan to monitor the member’s medication for safety and effectiveness.
10. Complete the established medication history: Check whether the member has taken the requested medication and provide details on the response to treatment.
11. For members who have never taken the medication, list any preferred agents they have tried and the reasons these are inappropriate.
12. In Section E, provide a letter of medical necessity and any additional information that supports the prior authorization request.
13. Finally, ensure the physician signs the document and include the contact person's name and phone number.
14. Once completed, users can save their changes, download, print, or share the form as needed.

Complete your forms online today to expedite your request for prior authorization.