Get State Of Connecticut Department Of Social Services Drug Prior Authorization Request Form Telephone

The STATE OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICES DRUG PRIOR AUTHORIZATION REQUEST FORM TELEPHONE is essential for obtaining prior authorization for medications. This guide provides a clear, step-by-step method to assist you in completing the form accurately online.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. In the prescriber’s section, enter the full name of the prescriber (last and first), their National Provider Identification (NPI) number, and contact information including their phone and fax numbers.
3. In the member’s section, fill in the member’s name as it appears on the CONNECT Card, their 9-digit identification number, and date of birth in MM/DD/CCYY format.
4. Optionally, include the pharmacy's fax number if it is known.
5. Specify the drug requested by entering its name (brand or generic) and the strength in milligrams.
6. Indicate the quantity being prescribed and the frequency of dosing.
7. Complete only the relevant sections for the type of prior authorization being requested to avoid denial due to incomplete requests.
8. Fill in any specific requests under the 'BMN Request', 'Early Refill Request', 'Non-PDL Request', or 'Optimal Dose Request' sections, providing necessary clinical justifications or symptoms where required.
9. The prescriber must sign the form and date it in MM/DD/CCYY format. Note that only the prescriber’s signature is acceptable.
10. After all fields are filled out, users can save changes, download, print, or share the completed form.

Complete your prior authorization request online for seamless processing.