Get () Prior Authorization Form - Coventry ...

Filling out the prior authorization form is an essential step for obtaining coverage for this medication. This guide provides a detailed and user-friendly approach to complete the form online effectively.

Follow the steps to complete the prior authorization form thoroughly.

1. Press the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Fill in the requesting physician's details, including the name, office contact information, office fax number, phone number, and office address.
3. Provide member information by entering the patient's name, date of birth (DOB), and member ID number.
4. In the medication information section, enter the date of the request and indicate the patient's diagnosis, selecting from the provided options.
5. Complete the required fields relating to previous therapies tried, noting the drug names, dates used, and therapeutic outcomes.
6. Add any additional comments that may support the request for prior authorization.
7. Ensure the physician's signature is provided to validate the authorization request.
8. Once all fields are completed, you can save your changes, download the filled form, print it, or share it as needed.

Complete your prior authorization form online today to ensure timely processing.