Get Prior Authorization Request Form Member ... - Optumrx

This guide provides a comprehensive overview on how to complete the Prior Authorization Request Form Member ... - OptumRx online. By following these steps, you will ensure that all necessary information is accurately reported to facilitate the approval process.

Follow the steps to accurately complete the form.

1. Press the ‘Get Form’ button to obtain the form and open it in the designated editor.
2. Begin by filling out the member information section. Enter the member's name, insurance ID number, date of birth, and street address. Ensure that all fields are complete to avoid processing delays.
3. Next, provide the provider information including the provider's name, NPI number, office phone number, specialty, and office street address.
4. In the medication information section, enter the medication name and its strength. Indicate whether this is a new start by selecting 'Yes' or 'No.' Include the directions for use and the dosage form.
5. For the clinical information, select the appropriate diagnosis from the provided options. If applicable, note any other diagnosis and its corresponding ICD-9/10 code.
6. List any medications the member has a failure, contraindication, or intolerance to by checking the relevant boxes.
7. Fill in the quantity limit requests by stating the quantity requested per day and providing a reason for exceeding plan limitations. Select the relevant reasons from the provided options.
8. In the comments section, include any additional information that may support the prior authorization request, such as other diagnoses, symptoms, or medications tried.
9. Review all information provided to ensure accuracy. Once completed, you may save changes, download, print, or share the form as needed.

Complete your documents online today to streamline your request.