Loading
Get Brand Exception Request Form - Carefirst
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Brand Exception Request Form - CareFirst online
Completing the Brand Exception Request Form - CareFirst is essential for requesting approval to use a brand-name drug instead of its generic alternative. This guide provides a clear, step-by-step approach to help users fill out the form accurately and efficiently online.
Follow the steps to successfully complete the Brand Exception Request Form.
- Click the ‘Get Form’ button to obtain the form and open it in the editor.
- Fill in the patient information section. Provide the patient's first name, last name, home phone number, home address, date of birth, insurance ID, work phone number, city, allergies, and group number.
- Complete the physician information section. Enter the physician's name, DEA number, office address, contact name, NPI number, city, phone number, state, fax number, and zip code.
- In the next section, complete the brand drug details by providing the brand drug name, strength, and dosage form.
- Provide a diagnosis that supports the request for the brand-name drug.
- Answer the questions regarding the patient’s treatment history. Indicate if the patient has experienced inadequate response to the generic alternative, and if the generic was deemed inappropriate for any clinical reason.
- Document any stabilization on a brand-name medication for specific conditions in the space provided.
- Complete the attestation statement and make sure the prescriber or authorized signature is provided, along with the date.
- Review all sections to ensure accuracy and completeness. Once verified, you can save changes, download, print, or share the form as needed.
Start filling out the Brand Exception Request Form online today to ensure timely processing.
What are examples of fax numbers? Fax numbers might look different depending on the location you're sending them to. A fax number sample is +1-907-555-1234 for the US and +44-20-1224-3456 for the UK. A fax number has three components that specify both the recipient and the sender's country, state, and local district.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.