Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to obtain the Prior Authorization Request Form and open it in your preferred online editor.
2. Complete the patient and physician information fields. This includes patient name, address, sponsor ID number, and date of birth in the designated areas.
3. Enter the physician's information, providing their name, address, phone number, and secure fax number.
4. Document the active ingredient(s) in the compound, as this information is crucial for the authorization process.
5. Fill out the clinical assessment section, including the diagnosis, route of administration, directions for use, proposed duration of therapy, and the reason for prescribing a compounded product instead of a commercially available product.
6. Indicate whether the patient has tried commercially available products for the diagnosis provided. If yes, proceed to document the products tried and the results of therapy.
7. Answer whether there is a current national drug shortage of a commercially available product that could be used.
8. Confirm if the prescribed route of administration matches the FDA-approved route for the active ingredient(s) in the compound.
9. Provide any additional information that might support the request.
10. Submit evidence with the form to support lawful marketing and safety of each ingredient, clinical appropriateness, and justification for the prescribed compounded product.
11. Finally, certify the information provided is true to the best of your knowledge by signing and dating the form.

Complete your Prior Authorization Request Form online today to ensure timely processing.