Get Welldynerx Prior Authorization Form

Completing the Welldynerx Prior Authorization Form online can help ensure a smoother process for obtaining necessary medication. This guide will provide clear, step-by-step instructions on how to fill out each section of the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the patient information section. Enter the patient’s full name, date of birth, identification number, plan name, and plan number in the appropriate fields.
3. Next, provide healthcare provider details. If additional space is needed, attach a separate letter with the necessary information.
4. Select the reason for the request from the listed options. If the reason is not among the options, indicate it under 'Other'.
5. Enter the medication name, strength, and sig. Also, fill in the anticipated start date of therapy.
6. Document any past medication trials along with their reasons for discontinuation. Include drug names, strengths, and specific dates for each trial.
7. List any contraindications related to formulary, alternative or generic medications.
8. Provide information regarding the diagnosis or concurrent disease states, including ICD-9 codes if available.
9. Fill in significant lab values that may support the need for the requested authorization.
10. Document the medical necessity reason or any relevant tear-off label use documentation.
11. If applicable, provide details for the quantity level limit exception, including specific dosing schedules and tapering information.
12. Confirm understanding of the False Claims Act by reviewing and signing the certification section. Include the prescriber’s printed name, signature, DEA/licensing number, NPI number, office phone, fax, address, city, state, and ZIP code.
13. Finally, ensure all sections are complete and accurate, then save changes, and prepare to share or print the form if required.

Complete your Welldynerx Prior Authorization Form online today for a smoother approval process.