Get Rx Prior Authorization Form

This guide provides users with a clear overview of how to complete the RX prior authorization form online. Follow these detailed steps to ensure all necessary information is submitted accurately and legibly.

Follow the steps to successfully complete the RX prior authorization form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section I, enter the patient's information including their full name, ID number, address, city, state, ZIP code, date of birth, and relationship to the cardholder. Ensure this information is complete and accurate.
3. In Section II, complete the physician's information. This should include the physician’s National Provider Identifier (NPI) number, full name, medical designation (MD, DO, etc.), address, city, state, ZIP code, phone number, prescribed drug, fax number, strength, daily dosage, and length of therapy.
4. Indicate infusion or injection location name and mention if the member has previously received the prescribed medication. If applicable, submit printouts from the pharmacy to indicate ongoing use.
5. Complete the diagnosis and ICD code, billing code, and provide information about any alternative drugs that have been used, including dates and treatment failures or adverse reactions if any.
6. If the patient is receiving weight loss drugs, ensure to document the necessary requirements, including BMI, visit dates, weight changes, and other related data.
7. In Section III, sign the fraud statement and certify that all information provided is accurate. Include the physician's signature and date.
8. If applicable, include the pharmacist’s signature for compound drugs and provide any necessary attachments, such as clinical notes or ingredient lists.
9. After completing all sections, users can save changes, download, print, or share the form as needed.

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