Get Coventry Prior Authorization Form

Completing the Coventry Prior Authorization Form online is a straightforward process that ensures your medication requests are reviewed efficiently. This guide provides clear instructions to help you fill out each section accurately.

Follow the steps to successfully complete the Coventry Prior Authorization Form.

1. Press the ‘Get Form’ button to access the Coventry Prior Authorization Form and open it for completion.
2. Enter the patient's name in the designated field, ensuring accurate spelling. Then, provide the member ID number, phone number, and date of request.
3. Fill in the date of birth (DOB) and plan ID. Next, indicate the benefit related to the request.
4. Specify the requesting physician's details, including their DEA number, office phone number, office fax number, office address, and tax ID number.
5. In the medication information section, specify the drug requested. Include the dose, frequency, and length of therapy.
6. If the medication is injectable, indicate where it will be administered by checking either 'Home (self-administered)' or 'Office administered.'
7. Provide the diagnosis details, ensuring to include office notes supporting this diagnosis.
8. List previous agents tried, including each drug, the date(s) used, and the outcome for each.
9. Use the other supporting information section only if requesting an exception to the plan's utilization management requirements.
10. Complete the physician’s signature and specialty fields at the bottom of the form.
11. Once the form is filled out completely, save your changes. You can then download, print, or share the form as required.

Complete the Coventry Prior Authorization Form online to streamline your medication approval process.