Get Prior Authorization Form Yes Yes No No - Dhhr Wv

Navigating the Prior Authorization Form can be challenging, but with this guide, you will find step-by-step instructions to complete the form accurately and efficiently. This guide aims to clarify each component of the form, ensuring a smooth online submission process.

Follow the steps to fill out the Prior Authorization Form online.

1. Press the ‘Get Form’ button to access the form and open it in your designated editor.
2. Begin by filling in the patient’s name. Enter the last name followed by the first name in the designated fields.
3. Next, enter the prescriber’s name in the respective fields, indicating last name, first name, and middle initial.
4. Provide the WV Medicaid 11-digit ID number and the patient's date of birth using the format MM/DD/YYYY.
5. Fill in the prescriber’s address including street, city, state, and zip code.
6. Input the prescriber’s 10-digit NPI number, phone number, and fax number.
7. If applicable, enter the pharmacy’s name and complete their address details, including street, city, state, and zip.
8. Document the pharmacy's 10-digit NPI number, phone number, and fax number, if relevant.
9. Indicate the drug name, strength, route of administration, and specific directions for use.
10. Provide the diagnosis along with the ICD diagnosis code if available.
11. Answer the questions regarding the patient’s age and severe chronic obstructive pulmonary disease (COPD) status. If applicable, provide details for the subsequent questions.
12. Document any medications the patient is using that are strong cytochrome P450 inhibitors. Include details about systemic steroids if applicable.
13. Enter any other pertinent information regarding the patient's health status or treatment.
14. Complete the attestation by signing the form, certifying that the request is medically necessary. Indicate the date of your signature.
15. Lastly, review all filled fields for accuracy. You can then save your changes, download, print, or share the completed form as per your needs.

Start filling out your Prior Authorization Form online today and ensure your submission is accurate and timely.