Get Prior Authorization Form For . Priror Authorization Form For Medicare Part B

Filling out the Prior Authorization Form for Medicare Part B can be essential for obtaining necessary medical treatments. This guide provides a comprehensive overview of each section of the form to assist users in completing it accurately and efficiently.

Follow the steps to fill out the form correctly.

1. To begin, click the ‘Get Form’ button to access the Prior Authorization Form. This will allow you to open the document and start filling it out.
2. In the 'Member' section, enter the last name, first name, date of birth (DOB), and gender of the member. Also include their member ID number and primary care physician's name.
3. Next, provide the information for the requesting provider. Fill in the provider's name, address, National Provider Identifier (NPI), phone number, fax number, contact name, and have the provider sign and date the form.
4. For the 'Product and Billing Information,' indicate the drug product being requested (e.g., 100 mg vial) and specify the place of administration as well as the start date or date of the next dose, last dose date, and dosing frequency.
5. Complete the 'Prior Authorization Criteria' section. List the patient's diagnosis, any previous treatments they have had, the date and result of the most recent tuberculosis (TB) test, and indicate if the patient has moderate to severe heart failure.
6. In the 'Additional Information' section, add any required information based on the patient's condition, including previous treatments attempted and responses to those treatments.
7. If there are any exceptions to the prior authorization requirements, indicate 'Yes' and provide detailed reasoning as required.
8. Once all fields are complete and legible, review the form for accuracy. After thorough verification, submit the form via fax to the provided numbers: 877.974.4411 toll-free or 616.942.8206.
9. Finally, you can save a copy of your completed form for your records before submission.

Encourage others to complete their documents online for efficiency and ease.