Get Affinity Prior Authorization Form

Filling out the Affinity Prior Authorization Form online is a crucial process for ensuring that patients receive the medications they need. This guide provides clear and detailed instructions for completing each section of the form accurately and efficiently.

Follow the steps to successfully complete the Affinity Prior Authorization Form.

1. Click ‘Get Form’ button to obtain the Affinity Prior Authorization Form and open it in the document editor.
2. Begin with the patient information section. Fill in the patient's first name, last name, middle initial, and date of birth. Ensure that all information is complete and legible.
3. Provide the patient’s member ID. This is essential for processing the authorization.
4. Indicate the patient's gender and whether they are transitioning from a facility. If applicable, provide the facility's name.
5. Move on to the provider information section. Enter the prescriber’s first name, last name, NPI number, phone number, address, and fax number. Ensure accurate contact information for communication purposes.
6. In the medication, medical, and dispensing information section, specify the medication name, strength, and the case-specific diagnosis or ICD-9 code. Indicate the frequency of the medication and the quantity required.
7. Select the refill options as necessary and specify the route of administration (oral, IM, SC, transdermal, IV, or other).
8. Answer the questions regarding the medication's dosage titration, FDA approval indication, and any treatment failures with preferred/formulary drugs. Provide details where necessary.
9. If applicable, attach relevant lab results or clinical notes that support the medical necessity of the medication and check the attachment box.
10. Read and attest to the accuracy of the information provided. Ensure you have all relevant documentation ready if requested.
11. Finally, sign and date the form. Submit the completed form via fax to the specified health plan number, including all supporting documents.

Complete your Affinity Prior Authorization Form online today to help ensure timely access to necessary medications.