Get Prior Authorization Form

Filling out the Prior Authorization Form online is a crucial step in obtaining approval for ® treatment. This guide provides clear instructions to help you navigate the form seamlessly, ensuring that you provide all necessary information accurately.

Follow the steps to successfully complete the Prior Authorization Form.

1. Use the ‘Get Form’ button to access the Prior Authorization Form and open it for editing.
2. Begin by entering the patient's name in the designated fields. Fill in the last name, first name, and middle initial.
3. Next, provide the prescriber's details, including their last name, first name, address, city, state, and their 10-digit NPI number.
4. Fill in the WV Medicaid 11-digit ID number for the patient along with their date of birth using the MM/DD/YYYY format.
5. Input the contact information, including the phone number and fax number for both the prescriber and pharmacy, if applicable.
6. Answer critical medical questions regarding hepatitis, liver failure, prior hypersensitivity to related medications, and confirm that the patient has been opiate-free for at least seven days.
7. Provide the diagnosis code along with an explanation of psychological support services being utilized during the ® treatment.
8. Certify that there have been no cash charges for the office visit related to the treatment of the patient's dependence or addiction.
9. In the attestation section, provide your electronic or manual signature and the date to certify that the information provided is accurate and medically necessary.
10. Review the completed form for accuracy, then save your changes, and you have the option to download, print, or share the form as needed.

Complete your Prior Authorization Form online today to ensure timely submission and approval.