Get Affinity Prior Authorization Form

Filling out the Affinity Prior Authorization Form online can seem daunting, but it is a crucial step in ensuring the necessary medication or treatment is approved. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to obtain the Affinity Prior Authorization Form and open it in your preferred editor.
2. Begin filling out the patient information section. Start with the patient's first name, last name, middle initial, and date of birth. Ensure that all information is complete and legible.
3. Input the member ID of the patient. Indicate whether the patient is male or female and whether they are transitioning from a facility. If yes, provide the name of the facility.
4. Next, complete the provider information section. Include the prescriber's first and last name, National Provider Identifier (NPI) number, phone and fax numbers, address, office contact, and specialty.
5. In the medication/medical and dispensing information section, fill out the medication name, strength, case-specific diagnosis/ICD9 code, frequency of administration, quantity, refills, and route of administration.
6. Answer the relevant questions regarding the medication's prior use, dosage titration, FDA approval status, and any previous treatment failures. Provide detailed explanations where required.
7. Attach any relevant clinical information, lab results, or other documents that support the medical necessity request, and indicate if additional documentation is attached.
8. Review all the entered information for accuracy, and ensure that the prescriber signs the form. Include the date of signature.
9. Once completed, users can save their changes, download the form, print it, or share it as necessary.

Take the next step towards obtaining necessary medical treatment by completing your Affinity Prior Authorization Form online today.