Get - Prior Authorization Request. - Prior Authorization Request

This guide provides clear instructions for completing the ® Prior Authorization Request. By following these steps, you can ensure that all necessary information is accurately submitted for timely processing.

Follow the steps to successfully complete your prior authorization request.

1. Click ‘Get Form’ button to obtain the Prior Authorization Request and open it in your preferred editor.
2. Begin by entering the patient’s name in the designated field.
3. Next, provide the patient’s ID number, followed by the physician’s name.
4. Indicate the specialty of the physician and provide their office telephone number.
5. Fill in the date and the patient’s date of birth, ensuring accuracy.
6. Enter the National Provider Identifier (NPI) number of the physician.
7. Provide the physician's office fax number.
8. In the section for prescribed medication, specify '®' or an alternative if applicable.
9. Record the patient's diagnosis, such as idiopathic pulmonary fibrosis, along with any other relevant details.
10. Enter the ICD code associated with the diagnosis.
11. Indicate whether the medication is prescribed by, or in conjunction with, a pulmonologist.
12. State if will be used in combination with ®.
13. If the patient is currently receiving , skip to question 13.
14. Confirm if the prescriber will collect liver function tests as recommended.
15. Answer whether the patient has a known etiology for interstitial lung disease.
16. Indicate if the patient has undergone a high-resolution computed tomography (HRCT) study of the chest and remember to attach the radiology report.
17. Specify the results of the scan in relation to interstitial pneumonia patterns.
18. Inform if a surgical lung biopsy has supported the diagnosis and attach the pathology report if applicable.
19. Mention if the diagnosis was discussed among qualified professionals as required.
20. Assess the patient's liver function tests and attach their results.
21. Finally, confirm if there has been a reduction in the disease progression and provide the required signature along with the date.
22. Once all fields have been filled out correctly, save your changes, download, print, or share the completed form as necessary.

Complete your Prior Authorization Request online today!