Get 8007109341

Filling out the 8007109341 form is essential for ensuring that your prior authorization requests are processed efficiently. This guide provides step-by-step instructions to help users complete the form accurately and successfully.

Follow the steps to complete the 8007109341 form online.

1. Press the ‘Get Form’ button to access the authorization request form and open it in your online document editor.
2. Begin with the provider information section, filling out the provider's name and NPI (National Provider Identifier) number. Ensure all details are correct to avoid processing delays.
3. In the patient information section, enter the patient's name, contact person at the office, Southern Scripts ID, Rx group number, physician's address (including street, city, state, and zip), patient's date of birth, patient phone number, provider specialty, prescription number, and pharmacy name.
4. Indicate whether the fax is secured by selecting 'Yes' or 'No.' Then fill in the provider's fax number and provide a phone number for contact.
5. Complete the diagnosis code and the date of diagnosis fields. It’s crucial to include accurate information for processing.
6. Check all applicable boxes related to the medication being requested, including medication name, strength, directions, and quantity per month. Indicate if this is a new medication or ongoing therapy and provide the start date if applicable.
7. Answer whether the patient has shown improvement while on therapy and complete the section about the place of administration, condition being treated, and type of treatment (acute or chronic).
8. Specify the severity of the disease and anticipated length of therapy. Additionally, indicate whether the patient has had a previous failure, intolerance, or contraindication to conventional therapies and provide details if applicable.
9. Include any other pertinent information to support the medical necessity of the request. Attach additional documentation, such as progress notes, if needed.
10. Finally, certify the accuracy of the information provided by signing and dating the form. Ensure all required fields are complete.
11. After completing the form, save your changes and download a copy. You can then print it out or share it as required, using the fax number provided to submit the completed form to the appropriate location.

Complete your 8007109341 form online now to ensure prompt processing of your prior authorization requests.