Get Prior Authorization Request Form 5% Topical ... - Medmetricshp

This guide provides a comprehensive overview of how to accurately complete the Prior Authorization Request Form for 5% topical patches. Follow these step-by-step instructions to ensure your request is processed smoothly.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the Prior Authorization Request Form and open it for editing.
2. Begin by entering the member’s FULL name in the designated box.
3. Provide the member’s NHP ID number in the specified field.
4. Fill in the member’s date of birth using the format (mm/dd/yy).
5. Enter the prescriber’s FULL name along with their specialty.
6. Identify and include a contact person at the office for communication.
7. Provide the prescriber’s fax and telephone numbers in the appropriate fields.
8. Indicate the requested drug, which in this case is (lidocaine) patch.
9. Specify the dose, frequency, and duration of the requested drug in the corresponding section.
10. State the diagnosis or indication for the request clearly.
11. Answer whether the member has a documented condition that prevents the use of oral medications, and if yes, provide the necessary details.
12. Complete the section regarding any previously tried medications. Check all that apply and note the response to each.
13. Write any prescriber comments in the provided textbox.
14. Sign the form certifying that the information is accurate, and provide the date of the signature.
15. After completing the form, you can save changes, download, print, or share the form as necessary.

Complete your Prior Authorization Request Form online today to ensure timely processing.