Get Prior Authorization Request Form Member ... - Optumrx

Filling out the Prior Authorization Request Form is a crucial step in ensuring that necessary medications are approved and provided promptly. This guide will walk you through each section of the form to help you complete it accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to access the form and open it in your editing tool.
2. Complete the Member Information section by entering the member's name, insurance ID number, date of birth, and address details.
3. Fill in the Provider Information section, providing the provider's name, NPI number, office contact details, and specialty.
4. In the Medication Information section, input the medication name, strength, whether this is a new start, directions for use, and dosage form.
5. Proceed to the Clinical Information section, selecting the relevant diagnosis and entering any applicable ICD-9/10 codes.
6. Indicate any medications that the patient has failed, had a contraindication, or an intolerance to, by checking the appropriate boxes.
7. Specify the requested quantity per day and provide reasons for exceeding plan limitations, selecting from the provided options.
8. Lastly, include any additional comments or relevant medical information that may assist with the authorization process.
9. Review all entered information for accuracy, then save your changes. You can choose to download, print, or share the form as needed.

Take action now and complete your Prior Authorization Request Form online for a smoother approval process.