Get Prior Authorization Request Form ... - Optumrx

Filling out the Prior Authorization Request Form is an important step in ensuring that your medication is approved by your insurance provider. This guide will walk you through each section of the form, providing clear instructions to help you complete it effectively.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. In the member information section, fill in the member's name, insurance ID number, date of birth, and contact details including street address, city, state, zip code, and phone number.
3. In the provider information section, enter the provider's name, NPI number, office phone, specialty, and office address, ensuring that all fields are completed as required.
4. Proceed to the medication information section. Here, specify the medication name, strength, and whether this is a new start for the medication. Also, include directions for use and dosage form.
5. In the clinical information section, indicate the relevant diagnosis by selecting one of the options provided, and enter the required ICD-9/10 codes. Provide medication history by answering if there has been prior use of specific drug combinations.
6. Answer the questions regarding quantity limits and any relevant comments. Provide any additional diagnoses, symptoms, or information that may assist in the review process.
7. Review the entire form for completeness and accuracy. Ensure all required fields are correctly filled in to avoid denial of your request due to missing information.
8. Once you have verified all entries, you can save changes to the form, download it for your records, print a copy for submission, or share it as necessary.

Start completing your forms online to streamline the authorization process.