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Get Prior Authorization Request Form/ Erythropoietic Agents ... - Optumrx
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How to fill out the Prior Authorization Request Form/ Erythropoietic Agents - OptumRx online
Completing the Prior Authorization Request Form for Erythropoietic Agents with OptumRx can seem daunting. This guide aims to simplify the process by providing clear instructions and highlighting important sections to ensure your submission is accurate and efficient.
Follow the steps to fill out the form correctly.
- Press the ‘Get Form’ button to access the Prior Authorization Request Form and open it for editing.
- Begin by filling out the patient information section. Ensure to include the patient’s name, insurance ID, date of birth, height, weight, address, and contact information. Remember to fill in the sex as required.
- Complete the provider information section. Include the provider’s name, ID number, address, phone number, fax number, state, zip, and specialty details.
- In the medication information section, specify the medication name, quantity, ICD9 code, directions for use, diagnosis, and number of refills. Don't forget to provide the physician's signature and indicate whether the physician will supply the medication.
- Fill in the medication instructions by confirming if the patient has been instructed on how to self-administer the medication and if it is a new start. If it is not a new start, provide the initiation date and the date of the last dose.
- Provide delivery instructions. Specify where the medication should be shipped, including either the physician's office or the patient’s address, and include the required date for the medication.
- If applicable, indicate the diagnosis for which the medication is prescribed. Check the appropriate boxes for conditions like Cryopyrin-Associated Periodic Syndrome or others, along with relevant confirmations regarding treatment and clinical responses.
- Finally, save any changes made to the form. You can then download, print, or share the completed form as needed.
Take the next step in the process and complete your Prior Authorization Request Form online to ensure timely approval.
Please call us at 800.753. 2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Prior Authorization criteria is available upon request.