Get Prior Authorization Request Form

Filling out the Prior Authorization Request Form accurately is essential for ensuring your request is processed efficiently. This guide provides clear, step-by-step instructions on how to complete the form online, helping you navigate each section confidently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in your browser.
2. Begin by filling out the member information section. This includes the member's name, insurance ID number, date of birth, and contact information.
3. Next, complete the provider information section. This requires entering the provider's name, their National Provider Identifier (NPI) number, and office details such as phone number and address.
4. In the medication information section, specify the medication name, strength, and dosage form. If you are requesting a brand name medication, check the appropriate box.
5. Indicate if this request is for a continuation of therapy by answering yes or no. If ‘yes’, provide answers to the follow-up questions regarding the member's medication history.
6. Complete the clinical information section by selecting the diagnosis that applies to the member, providing any relevant medication history, and including any additional comments or pertinent information.
7. After ensuring all required fields are filled out, review the form to check for completeness and accuracy.
8. Finally, save your changes and proceed to download, print, or share the completed form as necessary.

Complete your Prior Authorization Request Form online today for a smoother submission process.