Get 24 Hour Urgent Prior Authorization Request Form Complete Entire Form And Fax To

Completing the 24 Hour Urgent Prior Authorization Request Form is essential for obtaining timely approval for prescriptions. This guide will provide detailed instructions to ensure that each section of the form is filled out correctly and efficiently.

Follow the steps to complete and submit your authorization request.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin with Section A, which requires patient information. Fill in the patient's first and last name, date of birth (DOB), address, city, state, zip code, member ID number, and primary insurance details. Indicate any allergies the patient may have.
3. Specifically note whether the requested medication is new or a continuation of therapy and include the start date if applicable. Indicate if the patient is currently hospitalized by checking the appropriate box.
4. Move to Section B, which is focused on physician information. Enter the physician's first and last name, their specialty, NPI number, office address, phone, and fax information. Also, provide the office contact name and the fax attention to detail.
5. Next, specify the medication details, including strength, directions for use, diagnosis, prescribed dose, ICD-10 code, and frequency of administration. Be thorough in detailing the diagnosis to support your request.
6. Address questions regarding the patient's medical history, specifically if they have had a diagnosis of cancer in the past 730 days or have a history of antineoplastic agents within the last 365 days, and check 'yes' or 'no' accordingly.
7. Determine if the patient has a diagnosis of chronic non-malignant pain and whether they have tried other pain management therapies. Provide a detailed list where necessary.
8. Include medical justification for requesting a higher strength of as this information will be critical for the approval process.
9. Finally, verify if the patient has a pain management agreement with the prescriber, and have the physician sign and date the form.
10. Once all fields are accurately completed, save changes to the form, download it, and prepare for faxing it to the designated number.

Take action now; complete the authorization request form online to ensure timely processing.