Get Prior Authorization Request Form/ Monoclonal Antibody ... - Optumrx

Filling out the Prior Authorization Request Form for monoclonal antibodies can seem challenging, but this guide simplifies the process. By following the detailed steps outlined below, you will be able to complete the form efficiently and accurately, ensuring that you provide all necessary information.

Follow the steps to successfully fill out the form.

1. Press the ‘Get Form’ button to access the Prior Authorization Request Form. This will allow you to download and open the form in a suitable editor.
2. Begin by entering the patient information. Fill in the patient's name, insurance ID, date of birth, height, weight, and address details. Be thorough to avoid any processing delays.
3. Next, provide your provider information. Include the provider's name, ID number, address, contact information, and specialty. Accuracy in this section is crucial for proper identification.
4. In the medication information section, specify the medication name, dosage directions, quantity, diagnosis, ICD-9 code, and refills needed. Ensure that all medication details align with the patient's treatment plan.
5. The physician signature section is imperative. Confirm if the physician will supply the medication, and provide a signature if necessary. This step is critical for authorization.
6. Complete the medication instructions by indicating whether the patient has been instructed on self-administration, if the medication is a new start, and any pertinent dates regarding prior doses.
7. Fill in the delivery instructions, making sure to include the shipping address and the necessary date for medication reception. It is important to confirm details regarding delivery coordination.
8. Review all entries for accuracy and completeness. Once you are satisfied, proceed to save your changes, download, print, or share the form as needed.

Prepare your documents online to ensure smooth processing with OptumRx.