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

Filling out the Prior Authorization Request Form for monoclonal antibodies can be an essential step in ensuring your patient's medication needs are met. This guide offers clear instructions on how to complete the form accurately and efficiently online.

Follow the steps to effectively complete the form:

1. Select the ‘Get Form’ button to access the Prior Authorization Request Form and open it for editing.
2. Fill in the patient information section with accurate details, including the patient's name, insurance ID, date of birth, height, weight, and address.
3. Complete the provider information section, providing your name, provider ID number, contact details, and specialty.
4. In the medication information section, specify the medication name, dosage directions, quantity requested, diagnosis, and relevant ICD-9 code.
5. Include the physician's signature to confirm the details provided. This signature is necessary unless the medication is supplied directly to the patient.
6. Indicate whether the patient has been instructed on how to self-administer the medication and if this is a new start.
7. For any medications previously tried and failed, provide that information where indicated.
8. Specify the delivery coordination details, including the preferred shipping address and the date by which the medication is needed.
9. Review all entered information for accuracy and completeness before submitting your form.
10. Once everything is filled out correctly, users can save the changes, download, print, or share the completed form as needed.

Now that you have the guidance you need, complete your Prior Authorization Request Form online today.