Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the form and launch it in your preferred editor.
2. Begin by filling out the patient information section. Input the patient's name, insurance ID, date of birth, height, address, apartment number, city, state, zip code, phone number, alternate phone number, and sex. Ensure accuracy as this information is vital for identification and authorization.
3. Next, provide the provider's information. Fill in the provider’s name, provider ID number, address, city, suite number, building number, phone number, and fax number. This section identifies the healthcare professional who is requesting prior authorization.
4. In the medication information section, indicate the medication name, quantity, ICD-9 code, directions for use, diagnosis, refills required, and whether the physician will supply this medication. Be precise and check with the healthcare provider if needed.
5. Proceed to the medication instructions. Indicate if the patient has been instructed on self-administration and whether the medication is a new start. If it is not a new start, provide the initiation date and date of last dose. Supporting information may be requested in this area.
6. Complete the administration instructions. Specify the dispensing location, whether it is to be administered at the physician’s office, home health, self-administered, or long-term care. Fill out the date the medication is needed as well.
7. After filling out all relevant sections, review the entire form for accuracy. Ensure that all required fields are completed, as incomplete forms may lead to delays in processing.
8. Finally, after finalizing your entries, save the changes, download the form, print it, or share it as necessary. Be sure to fax the completed form back to the number provided, which is 1-800-853-3844.

Complete your prior authorization request online today to ensure timely processing of your medication.