Get Special Authorization Request Standard ... - Claimsecure

Filling out the Special Authorization Request Standard Form for ClaimSecure is a vital step in ensuring that you receive the necessary authorization for your healthcare needs. This guide will walk you through each section of the form online, ensuring you provide all required information accurately and completely.

Follow the steps to complete your Special Authorization Request form effectively.

1. Click the ‘Get Form’ button to access the form and open it for editing.
2. Begin by filling in the Plan Member section. Include the Group Number, Certificate Number, and the Patient Name.
3. Indicate your relationship to the member by selecting one of the options: Self, Spouse, or Other. Then enter your complete Street Address, City, Province, and Postal Code.
4. Provide your Telephone Number and the Patient Date of Birth in the required format (YYYY/MM/DD).
5. If you prefer a response via email, enter your email address. Alternatively, indicate whether you wish to use the email associated with your eProfile account for the response.
6. Review and authorize the necessary consent for information exchange under the health benefit program by signing and dating the form.
7. If applicable, complete the Spousal Coverage section by detailing coverage under your primary drug plan and whether you have applied for Special or Prior Authorization.
8. Proceed to the Provincial Coverage section, indicating whether you have applied for coverage under the provincial plan and provide any necessary documentation.
9. Fill out the Patient Assistance Program section if you are registered. Provide required case information and contact details if applicable.
10. Complete the sections for the physician's input, providing details such as Physician Name, Specialty Qualification, and the required Drug requested for Special Authorization.
11. Finish filling in all clinical information, diagnostics, and additional documentation as required.
12. Once all fields are completed, save your changes, and prepare to download, print, or share the form as necessary.

Complete your Special Authorization Request form online today to ensure timely processing of your request.