Get Medication Prior Authorization Form Fax Back To: 18775779045 Member Information Last Name: Phone

Filling out the Medication Prior Authorization Form is essential for ensuring that patients receive timely approval for necessary medications. This guide provides step-by-step instructions to help users navigate the form accurately and efficiently.

Follow the steps to complete the form effectively.

1. Press the 'Get Form' button to access the Medication Prior Authorization Form. This will allow you to open the document in an editable format.
2. Fill in the 'Member Information' section. This includes entering the last name, phone number, date of birth, first name, and ID number. Ensure all information is accurate and legible.
3. Indicate the type of plan by checking the appropriate box: 'Medicaid,' 'Medicare,' or 'Standard.' If applicable, check the 'Expedited' box to request an expedited review for urgent cases.
4. Complete the 'Prescriber Information' section. Here, the prescriber's name, NPI (National Provider Identifier), phone number, fax number, and specialty should be entered. Double-check for correct information.
5. In the 'Medication Requested' section, provide details about the medication including name, strength, quantity, and directions for use. Be specific to avoid confusion during the approval process.
6. Document the estimated duration of therapy and the relevant diagnosis along with any pertinent clinical information that supports the request.
7. List any previous medications tried for the diagnosis, including when they were administered, along with the outcomes and reasons for any intolerance to the formulary medication.
8. If applicable, include recent clinical documentation for reauthorization requests in the designated area.
9. Ensure that the prescriber signs and dates the form at the bottom before submission.
10. Review the form to make sure all sections are complete and legible. Missing or illegible information may delay the review process.
11. Fax the completed form, along with any required clinical documentation and prescription, to 1-877-577-9045 for processing.

Complete your documents online to expedite the process and ensure timely medication delivery.