Get Print Form Alaska Medicaid Prior Authorization Form Reset Form Fax This Request To: 1-888-603-7696

This guide provides step-by-step instructions on how to complete the Print Form Alaska Medicaid Prior Authorization Form efficiently. By following these instructions, you can ensure that all necessary information is accurately provided, reducing the likelihood of delays.

Follow the steps to successfully fill out the form.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Complete the member information section by entering the last name, first name, ID number, date of birth, and sex. Ensure all information is legible and accurate to avoid any delays in processing.
3. In the prescriber information section, fill out the last name, first name, NPI number, phone number, and fax number. This identifies the healthcare provider requesting authorization.
4. For the request section, select the appropriate dosage (either 50 mg or 100 mg) and fill in the corresponding NDC number and quantity. Specify the requested start date for the medication.
5. Detail the rationale for prior authorization, including gestational age in weeks and days, weight in kilograms, and relevant clinical diagnoses. Complete the checklist for applicable medical treatments to strengthen the application.
6. Ensure the prescriber signs and dates the form to validate the request. An unsigned form may lead to processing delays.
7. Once you have filled out the form, review all entries for completeness and accuracy. Users are encouraged to save their changes, download the completed form, or print it for submission.
8. Finally, fax the completed form to 1-888-603-7696 as instructed, or consider mailing it to the address provided in the document if that is more convenient.

Begin completing your documents online today!