Get Prior Authorization Request Form - Ehim

This guide provides a clear, step-by-step approach to completing the Prior Authorization Request Form - EHiM online. Each section of the form is broken down to help users navigate the process smoothly and effectively.

Follow the steps to complete the Prior Authorization Request Form successfully.

1. Click ‘Get Form’ button to access the Prior Authorization Request Form and open it for editing.
2. In the 'Member Information' section, fill out the patient name, cardholder ID, and birth date. Be sure to enter both the primary and secondary medical coverage details.
3. In the 'Practitioner Information' section, provide the doctor's name, office contact information, group number, and specialty.
4. Complete the 'Medical Information' section by specifying the medication requested, dose, expected duration of treatment, and the diagnosis or reason for the request.
5. If applicable, include pertinent labs or diagnostic test results in the designated area.
6. List any other medications used to treat the condition along with the corresponding dates.
7. Document the outcomes of previous treatments or medications used.
8. Ensure that the doctor’s signature and the date are included at the bottom of the form.
9. For 'EHIM Use Only', note the Prior Authorization Reference number and any other relevant information as directed.
10. Finally, save changes to the completed form, and explore options to download, print, or share it for submission.

Begin filling out the Prior Authorization Request Form online now to streamline your process!