Follow the steps to complete your authorization request online.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Begin by entering the prescriber’s information. Fill in the last name, first name, DEA/NPI number, specialty, phone number, and fax number as required.
3. Next, move on to the member information section. Input the member's last name, first name, member ID number, and date of birth.
4. In the medication information section, provide the drug name along with its strength, quantity, and dosing instructions.
5. Then, specify the diagnosis and duration fields. Make sure to enter all necessary details accurately.
6. You will then need to answer all required questions regarding the patient’s age, diagnosis of pseudobulbar affect, and any underlying conditions like Amyotrophic Lateral Sclerosis or Multiple Sclerosis.
7. Ensure that you have attached all requested fax documentation, such as lab results, to avoid any delays in the clinical review process.
8. Finally, provide your prescriber or authorized signature, include the name and title of the authorized medical staff, and the date of completion.
9. Once all fields are filled out and confirmed, you can save your changes, download the completed form, or print it for submission.

Complete your documentation now by filling out the 877 228 7909 form online.