Get Idiopathic Pulmonary Fibrosis Ipf Pirfenidone Nintedanib Prior Authorization Physician

Filling out the Idiopathic Pulmonary Fibrosis (IPF) Pirfenidone Nintedanib Prior Authorization Physician form is essential for obtaining authorization for prescribed medication. This guide will provide clear instructions to help you navigate the process efficiently and accurately.

Follow the steps to complete the authorization form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the patient information section. Provide the current date, the patient's full name, address, ID number, date of birth, telephone number, and group number.
3. Next, complete the physician/clinic information. This section requires the prescriber's name, National Provider Identifier (NPI) number, specialty, clinic name, address, phone number, contact name, and secure fax number.
4. Attach any additional information that may be relevant to the request, including the patient’s diagnosis with ICD code and description, medication requested, strength, dosing schedule, and quantity to be provided per month.
5. Answer the series of medical questions accurately. These include tests related to forced vital capacity, smoking status, exposure to environmental factors, presence of active infections, and diagnostic confirmations. Each question requires a 'Yes' or 'No' answer, and if 'Yes' is selected for specific questions, additional details may be needed.
6. Review the specific criteria needed for a diagnosis of usual interstitial pneumonia (UIP). Ensure you answer questions relating to HRCT scans and any biopsies conducted.
7. Confirm whether definitive IPF has been diagnosed by a specialist. Provide the type of specialist if applicable.
8. Indicate whether the patient will be taking both and simultaneously.
9. After completing all sections, finalize the form by reviewing all entries for accuracy. Once confirmed, you will have the option to save changes, download, print, or share the completed form.

Start your authorization process online today by completing the form.