Get Prior Authorization Form - Priority Health

Filling out the Prior Authorization Form for Priority Health may seem challenging, but this guide will simplify the process for you. By following the step-by-step instructions provided, you can confidently complete the form online and ensure that your request is properly submitted.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access and open the form in your preferred document editing tool.
2. Begin by entering the member's last name, first name, and ID number in the designated fields. Make sure that the information is accurate to avoid processing delays.
3. Fill in the date of birth (DOB) and gender of the member as required.
4. Provide the requesting provider's details, including their name, address, National Provider Identifier (NPI), phone number, and fax number.
5. Ensure that the provider's signature and the date are included to validate the request.
6. In the product information section, check whether this is a new request or a continuation request, and select the appropriate option.
7. Enter the drug product information, specifying ' 30 mg/3 mL syringe', and include the start date, the date of the last dose (if applicable), and the dosing frequency.
8. If applicable, answer the precertification requirements by detailing the patient's diagnosis, specifying hereditary angioedema or another condition, along with the rationale for use.
9. Indicate the dates of the last three injections of , if the patient has previously used this medication.
10. Review all fields to ensure that they are complete and legible, as this is essential for the review process.
11. Finally, save your changes. You can then download, print, or share the completed form as needed. Make sure to fax the completed form to the appropriate numbers provided.

Take the next step and complete the Prior Authorization Form online today.