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Get () Support Center Assistance Form This Form Is To Be Used For Prior Authorization
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How to use or fill out the ® Support Center Assistance Form This Form Is To Be Used For Prior Authorization online
Filling out the Support Center Assistance Form is a crucial step for obtaining prior authorization assistance. This guide will walk you through each section of the form, providing clear and supportive instructions to ensure you complete it accurately and efficiently.
Follow the steps to fill out the support center assistance form online
- Click ‘Get Form’ button to access the Support Center Assistance Form and open it in the designated online environment.
- Complete the patient information section by providing the patient's full name, date of birth, address, and contact numbers. Ensure that all fields are filled accurately as this information is essential for the assistance process.
- Enter prescriber information, including the prescriber's full name, phone number, NPI number, and DEA number. This section is critical as it verifies the medical professional responsible for the patient's treatment.
- In the clinical information section, indicate whether the patient has seizures associated with Lennox-Gastaut syndrome. Provide detailed information about anticonvulsant medications that have previously been tried, including reasons for discontinuation.
- List any anticonvulsant medications the patient is currently taking, along with the drug strength, prescribed quantity, and directions for use. This information aids in assessing the patient's current treatment plan.
- Authorize the use of by affirming its medical necessity and accuracy of the provided information. The prescriber must sign and date the form to validate the authorization.
- Finally, ensure the form is completed in its entirety. Save your progress, and once verified, you can download, print, or share the form as required. If you have any questions, contact the Support Center for assistance.
Take the first step toward obtaining necessary support by completing the Support Center Assistance Form online.
Except for emergency services, post-stabilization services, and services provided to you during an approved inpatient admission, all services from an out-of-network provider must be prior authorized. Claims for services from out-of-network providers that are not approved before the service is given may be denied.
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