Get Prior Authorization Request Form - New Hampshire Healthy Families

Completing the Prior Authorization Request Form for New Hampshire Healthy Families can be straightforward when you follow the proper steps. This guide will walk you through each section of the form to ensure that you provide all necessary information clearly and accurately.

Follow the steps to effectively complete the Prior Authorization Request Form.

1. Press the ‘Get Form’ button to access the Prior Authorization Request Form and open it in your chosen editor.
2. Begin by filling out the member information section. Include the member's name, ID number, date of birth, address, primary and alternate phone numbers, and any medication allergies.
3. Next, complete the prescriber information section. Fill in the prescriber's name, NPI or DEA number, specialty, group or hospital name, address, phone number, and fax number.
4. In the medication requested section, specify the drug name, dosage/strength, dosage form, route of administration, quantity per day, directions for use, refills or length of treatment, and the therapy start date.
5. For the diagnosis section, indicate the relevant diagnosis, the ICD9 code and description, and the date of diagnosis. Remember to attach any diagnostic clinicals as needed.
6. In the medication history section, answer whether the member is currently taking the prescribed medication, if this request is for a continuation, and provide information regarding any previous treatments, including drug names, strengths, dosages, dates of therapy, and reasons for discontinuation.
7. Complete the rationale for request and pertinent clinical information section, check relevant boxes indicating medical intolerance, inadequate response, absence of appropriate formulation, or other reasons. Provide supportive clinical information as required.
8. Finally, ensure both prescriber signatures and dates are included in the appropriate places to finalize the document. After reviewing all entries for accuracy, users can save changes, download or print the completed form for submission.

Start filling out the Prior Authorization Request Form online today to ensure timely processing of your request.