Get () Prior Authorization Request Form ...

Filling out the ® () Prior Authorization Request Form online can streamline the process of obtaining necessary medication for patients. This guide will help you navigate each section of the form with clear, step-by-step instructions to ensure all required information is accurately provided.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin by completing the Member Information section. Provide the member's name, insurance ID number, date of birth, and contact information as required.
3. Next, fill out the Provider Information section. Include the provider's name, NPI number, office phone, and address. Make sure this information is accurate to facilitate communication.
4. In the Medication Information section, enter the name and strength of the medication being requested. Specify if this is a new start, and provide directions for use and the dosage form.
5. Proceed to the Clinical Information section. Select the appropriate diagnosis from the options provided or specify another diagnosis, including relevant ICD-9/10 codes.
6. Acknowledge the risk acknowledgment questions regarding patient age and medication efficacy. Ensure the responses reflect the provider's stance.
7. Detail any medications the patient has failed, contraindicated, or had an intolerance to as part of the previous therapy history.
8. Indicate the quantity limit requests by stating the requested quantity per day and providing a reason for exceeding plan limitations.
9. Complete any additional comments or relevant information that might support the request, making sure to include diagnoses, symptoms, and medication history.
10. Once you have filled out all required fields, review the form for accuracy. Save your changes, and then choose to download, print, or share the completed form as needed.

Take the first step towards securing medication by filling out the Prior Authorization Request Form online today.