Get () Drug Form Non-acro Providers

Completing the () Drug Form NON-ACRO Providers online is a straightforward process designed to facilitate preauthorization requests. This guide will provide step-by-step instructions to help you accurately fill out each section of the form.

Follow the steps to effectively complete your drug form.

1. Press the ‘Get Form’ button to obtain the document and open it in your online editor.
2. In Section I – General Information, enter the initial start date of therapy and the anticipated date of the next infusion. Make sure to include all relevant dates for accurate processing.
3. Proceed to Section II – Member Information. Here, enter the member's name, plan type, member ID, and date of birth. Ensure that all details are accurate to avoid delays.
4. Next, fill out Section III – Provider Information. Provide the requesting provider's name, address, telephone number, office contact name, and place of service. Additionally, include the provider's CBC number, NPI number, and fax number.
5. In Section IV – Preauthorization Requirements and Clinical Criteria, indicate the appropriate ICD codes for asthma or chronic idiopathic urticaria. Fill out the age section and select the relevant criteria based on the patient's condition.
6. Document treatment requirements and any testing information, including blood tests or skin tests, providing dates where applicable. Use this section to specify the requested doses and ensure they align with the package labeling.
7. If necessary, check the option to submit additional comments and medical documentation to support your request.
8. Finally, ensure the dosing information is completed. Calculate patient weight in kilograms and input the exact doses as per the treatment plan.
9. Review all sections for accuracy. Once complete, you can save the changes, and download, print, or securely share the form as needed.

Complete your () Drug Form NON-ACRO Providers online today to ensure timely preauthorization.