Get Prior Authorization Request Form Member ... - Optumrx

Filling out the Prior Authorization Request Form Member ... - OptumRx correctly is essential for ensuring timely processing of requests. This guide provides step-by-step instructions to help you navigate each section of the form online.

Follow the steps to complete your form efficiently.

1. Use the ‘Get Form’ button to obtain the Prior Authorization Request Form and open it in your preferred editing tool.
2. Enter member information in the designated fields. This includes the member's name, insurance ID number, date of birth, and address details.
3. Provide the provider information, including the provider's name, National Provider Identifier (NPI) number, office phone, and office fax details.
4. Fill out the medication information section. Input the medication name, strength, and dosage form. Indicate if this medication is a new start by selecting 'Yes' or 'No.'
5. Detail the directions for use of the medication. Make sure all required fields are filled accurately.
6. In the clinical information section, choose the relevant diagnosis from the options listed, or provide an alternative diagnosis along with the corresponding ICD-9/10 code.
7. Indicate if is being administered in conjunction with ulcer wound care and provide any additional comments or relevant patient information as necessary.
8. Review all entered information to ensure accuracy. Any missing information may result in denial of the request.
9. Once you have completed the form, you can save your changes, download the form, print it, or share it as needed.

Take action today and complete your Prior Authorization Request Form online for a smoother process.