Get Coventry Prior Authorization Form

The Coventry Prior Authorization Form is an important document required for certain medications that need prior approval before being prescribed. This guide provides clear, step-by-step instructions on how to efficiently complete the form online, ensuring you have all necessary information ready for submission.

Follow the steps to complete the Coventry Prior Authorization Form online.

1. Use the ‘Get Form’ button to access the Coventry Prior Authorization Form. Once you click this button, the form will open in an editor for you to fill out.
2. Begin filling out the requesting physician information. Include your name, call center ID, office contact, tax ID number, plan ID, benefit, office fax number, phone number, and office address.
3. Provide member information by entering the patient's name, date of birth (DOB), member ID number, and the date of the request.
4. In the medical information section, enter the drug requested, along with the dosage (including strength and frequency) and the duration of treatment.
5. State the diagnosis relevant to the request and list other medications that the patient has tried. For each medication, specify the drug name, dates used, and the outcome of the treatment.
6. Include any additional supporting information that may strengthen your request. This is crucial when seeking exceptions based on medical necessity.
7. Add any comments or additional insights in the additional comments section, which can provide further context for the request.
8. Lastly, ensure the form is signed by the physician. Please also input the physician's specialty.
9. Once all fields are completed, save your changes. You can then download, print, or share the form as necessary for submission.

Take the necessary steps to complete the Coventry Prior Authorization Form online to ensure a smooth approval process.