Get Prior Authorization Request Form/ Interferons/ Hepatitis ... - Optumrx

Filling out the Prior Authorization Request Form for Interferons and Hepatitis medications through OptumRx can streamline the process of obtaining necessary approvals for treatment. This guide offers clear and supportive instructions to help users navigate the form effectively.

Follow the steps to complete your Prior Authorization Request Form.

1. Press the ‘Get Form’ button to access the Prior Authorization Request Form.
2. Provide patient information such as name, date of birth, height, weight, and address. Ensure that the Insurance ID is entered accurately for verification purposes.
3. Next, fill in the provider's information including the provider's name, specialty, and contact details. Make sure to include both the provider ID number and the fax number accurately.
4. In the medication information section, list the medications being requested, including dosage directions, quantity, and refills. Confirm whether the physician will supply each medication directly.
5. Fill out the physician signature section appropriately, indicating whether prescriptions will facilitate delivery or if the physician will supply medications directly to the patient.
6. Complete the medication instructions section, confirming if the patient has been educated about self-administration and whether the request is for a new treatment start.
7. For delivery instructions, select the desired shipping location for the medication and indicate the date the medication is needed, ensuring all fields are completed.
8. Attach any necessary clinical information that supports the diagnosis, as additional documentation may be needed based on the patient’s insurance coverage.
9. Once all sections are filled out, review the form for accuracy, then save the changes, download or print the form as needed, and prepare to fax it to the provided OptumRx fax number.

To ensure timely processing, fill out your Prior Authorization Request Form online today.